One of the most challenging jobs we do in chronic pain management is help people get their heads around what chronic pain is…without giving them the idea that we think they’re imagining it, they’re mentally unwell, they’re ‘pretending’, ‘malingering’ or otherwise ‘not coping’.
While I can’t say I’ve got the answer, after explaining what pain is for a few years (not telling how many!), there are some things I find work better than others…
The first thing is to have a bunch of examples of everyday pain (mainly acute pain) to act as examples – mine include getting a flu jab, sunburn, a stubbed toe, sports bruises, and shark bites! This helps people understand that pain is a normal, everyday experience that is understable. Challenging, but understandable!
I use two different models of pain to help give people a bit of an understanding of their pain. The first is a biopsychosocial model – so I have three circles, and while I’m talking with the person and getting them to tell me what their pain is like and how it’s affecting them. The three circles are the ‘bio’ or biophysical factors, ‘psycho’ or psychological factors, and ‘social’ which includes social and cultural factors.
I find that working from what people already agree about (ie what they identify for themselves) and working with that to develop an explanation using a framework, like the one above, avoids saying which comes first (the pain or the irritability), and helps people acknowledge that each part influences the other.
Another option is to use Loeser’s ‘onion rings’ model. This is a model that helps place the pain experience in context – it helps put the biophysical factors in the centre (whether as initiator or maintainer of the pain), while ensuring that the other aspects of pain such as the behaviour and context are also in place.
At the centre of the ‘onion’ is nociception – today we might instead think about neuromatrix dysfunction – which initiates and probably maintains the biophysical aspects of the pain experience. But without the next few components, the pain experience does not actually exist. We need to attend to or judge the meaning of the information being transmitted to the brain before it can be experienced…
So the next part is the actual quality or experience of pain – this is the part we can’t share with another, no matter how much we want to. This is directly influenced by the nociception/neuromatrix part, but is also influenced by the next layer – which is our judgement of the meaning of that experience. Loeser describes this as ‘suffering’ – but while experiencing pain may not be optional, suffering certainly is!
Suffering is all about how we interpret the sensations we become aware of, arising from the neuromatrix or nociceptors. Suffering includes our predictions of the implications of the pain, what we think the pain means (something serious? something that will mean we can avoid something unpleasant? something to worry about…). Some pain we can interpret as good – the pain after exercising, or the pain of childbirth (really!), while other pain we are concerned about (is it cancer? am I dying?).
What we do about pain is action, or behaviour. Pain behaviours are directly influenced by what we think is going on – we run away if we think it’s something harmful, if we think it’s helpful we’re more likely to tolerate it (think about the flu jab compared with being jabbed with a dirty syringe in a dark alley). At the same time, pain behaviours are influenced by our social setting – we do different things depending on who is around us, and where we are!
So the final ring is the social context – where we are at the time, the response of other people, our culture and even the legislative setting in which we live and work – these all make a difference to our pain behaviour (think of the response to stubbing your toe in your garage compared with your response to stubbing your toe on a pew at a funeral).
Working from what the person tells us, to a framework or model, seems to help people understand that we know what’s going on for them, we understand they’re not going nuts, and that we do know what we’re talking about. A bit of reflective listening doesn’t hurt either.
I’ve also attached this description if you want something more complex…simple-explanation-of-cp
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Now it’s time to turn to the details of the biopsychosocial model as it is applied to pain. There are some excellent resources available to look at this in both a simple way, and in much greater detail.
This site is written by a physiotherapist – and contains some well-written and reasonably simple information both about pain and more especially about low back pain. I’d suggest heading to this page on biopsychosocial model for a quick overview.
As far back as 1953, pain has been seen as more than simply either body or mind…
Pain is no longer considered exclusively either as a neurophysiological or a psychological phenomenon. Such a rigid dichotomy is obsolete, because pain is now recognised as the compound result of physiopsychological processes whose complexity is almost beyond comprehension.
The Management of Pain J Bonica Lea & Febiger 1953 (more…)
With such a wide array of factors influencing a person’s pain experience, it can be difficult to decide exactly what to include in a pain assessment.
We do know that the model we use to view pain will influence the factors that are included – and although the internationally accepted model of pain is a biopsychosocial one, there are any number of versions of this model that can be adopted.
Within each domain of the biopsychosocial model the research over the past few years has exploded, meaning there are more and more factors than can be considered – and these need to be organised in a systematic way so that we can make sense of them, make good clinical decisions about interventions and then work with the person who has the pain so they can understand them and contribute.
There are a couple of fundamental things we should always have as guiding principles:
- No single element in the biopsychosocial model of pain is more (or less) important than any other
- All three domains must be assessed to fully understand the ‘four p’s’ of a pain presentation:
- Predisposing factors
- Precipitating factors
- Perpetuating factors
- Protective factors
- The fundamental questions to be answered through assessment are
- ‘What brought this person to this place with this problem today?’
- ‘What can be done to reduce distress and disability?’
- Simply asking the person with pain provides some good information, but on its own is probably inadequate. Interviews need to be supplemented with:
- History – from relevant documentation (from the referrer, other health care notes, previous consultations within your facility)
- Observation – structured or unstructured observation from the moment the person enters your clinic, to the time they leave
- Clinical examination or testing – including functional performance as well as pen and paper questionnaires
- Other people – particularly partners or other family members
- Assessment only begins the process of developing a working set of hypotheses about what might be ‘true’ for this person at this time for these problems
A couple of models that can be helpful:
This one is from Robert Gatchel (Gatchel, 2004).
Another model I like is by Tim Sharp, published in 2000, which is somewhat less complicated than Gatchel’s one, but still has a whole lot of arrows! Dr Sharp now runs a successful consulting practice listed in my blogroll, worth a look!
Of course, no matter what model you use, under each ‘heading’ you will need to continue to update relevant research into specific factors to include (eg ‘appraisals’ would now routinely include catastrophising and pain-related anxiety, while ‘motor behaviours’ would include avoidance, safety behaviours, as well as task persistence). And after deciding what to include, it will be just as important to determine the best way to access the information – through questionnaire, observation, history, testing or interview.
Finally, it will be important to work out a structured way to put the information collected together so it can be readily understood and used as the basis for hypothesis testing.
I’m not sure I’ve got a handle on this part yet – but I’m keen to hear what you use, or how you think this part can be structured. I think we’ll have to draw on research from small group/teamwork literature into decision-making, and on human cognition and information processing to inform us on the best way to integrate such complex information without jumping to conclusions.
Isn’t it great the way that answering one question leads to a whole lot of new bits of research? Can ya tell how much I love questions?!
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Gatchel, R. (2004). American Psychologist, 59, 792-805
Sharp, T. (2000). Chronic pain: A reformulation of the cognitive-behavioural model. Behaviour Research and Therapy, 39, 787–800
For a therapy that has great empirical support and can be used by any and all members of the interdisciplinary team, you can’t really go far from cognitive behavioural therapy. Waaaay back in the olden days when I was originally trained as an occupational therapist, CBT was the province of psychologists only – and possibly there are a few out there who would like it to stay that way! But in pain management it’s vital to integrate CBT throughout the whole team so that consistent responses are made. So this week I’ll be covering some practical ways to use CBT within ‘other’ therapies – especially physiotherapy and occupational therapy.
I’m not going to review the many studies demonstrating support for CBT, this is a practical series, so the first step is probably working out how to introduce CBT to a client. Several key principles inform my practice – the first is that we are collaborating. That means I am no expert on what will work best for this client (and I don’t have a complete understanding of what is going on for that person either!). This helps me from ever thinking that I’m superior to him or her – we are in this together!
The next principle is that we are developing an understanding over time – the therapy process is really a journey of discovery. Some of the things I suggest may not be appropriate – or it may not be the right time to introduce them.
And further – eventually this person is going to do this for themselves. I don’t want to be a long-term therapist!
And finally, CBT in the management of chronic pain is not a personality overhaul – we’re not trying to make this person ‘different’, we’re hoping they will understand a bit more of what is happening, that they can learn new ways of viewing their situation, and that they can develop a range of ways to manage in their situation so they can choose.
A great book that has some lovely worksheets and puts CBT into a framework that I find helpful is Renee Taylor’s ‘Cognitive behavioral therapy from chronic illness and disability’ (2006) Springer:New York. ISBN-10: 0-387-25309-2
I’ll be dipping in and out of it throughout the week – as well as referring to some articles and other books I have in my library. (You don’t want to know how many books I have!!)
How do OT’s and Physio’s use CBT? It depends a little on the activities you are undertaking – so here’s my quick take on it.
- There are opportunities to provide information (on request) about the effect of thinking on emotion and coping. Times such as when a person starts learning about factors that influence their pain – stress, fatigue, anger.
- When introducing a form of activity pacing or working to quota often provides an opportunity to ask ‘what went through your mind when we started to talk about this?’
- When the person starts doing an activity and demonstrates a shift in emotion/affect or similar – again, asking ‘what went through your mind when I suggested we do this?’
- When the person has been invited to continue with an activity in between sessions and doesn’t manage it.
- When providing information about a model of chronic pain.
- When emotions are evident.
- When helping the person generalise a coping skill such as self regulation breathing or setting goals
Do you get the idea that there isn’t really any time when you can’t use CBT?!
More about this tomorrow – in the meantime, consider this: When you start to think about thinking, what happens?
Supervision has both a good reputation and a not so good – for me it’s been a mixed blessing because I have rarely had effective supervision from an occupational therapist (with the exception of my current occupational therapy supervisor!), and in fact the majority of my clinical supervision has been from psychologists.
I’ve posted much more about supervision in the Occupational Therapists Only section of my blog – there are some specific issues for occupational therapists that I want to grapple with – but here are some general thoughts on how supervision works for me, both as a supervisee and a supervisor.
Supervison for me entails someone else to challenge my thinking – I know I have cognitive biases that I am not aware of (we all do), and I need someone to challenge me in case I’m working an assumption that I’m not aware of.
Supervision also involves the process of talking which can help with formulating the information that is flying around in my head. By selecting and and putting together pieces of information to transmit my thoughts, I am actively processing in a different way from when I’m documenting assessment findings, or therapy process. The talking part involves me clarifying by using the clinical model that helps to explain what I’m seeing.
Supervision for me isn’t typically about me talking about my personal responses to a given clinical situation (as in, how do I feel about the therapy with this person, how am I coping). That aspect is something I prefer to deal with abstractly using music, dance, art, photography. I’m not sure that talking about how frustrated I am with someone, or how disappointed I am with someone does anything for me apart from encourage me to invest expectations in the person – when it’s their choice as to what they want to do next.
Supervision can be a form of therapist control. I’ve experienced this in the past where a therapist used supervision as an opportunity to rein in and dictate therapy practice, and discourage exploring issues. ‘Do it this way’ was the motto, with little encouragement to reflect, and most importantly for me, no evidence that ‘this way’ was any more effective than any other way.
Hawkins and Shohet, quoted by Smith, M. K. (1996, 2005) ‘The functions of supervision’, the encyclopedia of informal education, Last update: December 28, 2007, suggests the following foci for supervision.
The primary foci of supervision (after Hawkins and Shohet 1989)
|To provide a regular space for the supervisees to reflect upon the content and process of their work||Educational|
|To develop understanding and skills within the work||Educational|
|To receive information and another perspective concerning one’s work||Educational/Supportive|
|To receive both content and process feedback||Educational/Supportive|
|To be validated and supported both as a person and as a worker||Supportive|
|To ensure that as a person and as a worker one is not left to carry unnecessarily difficulties, problems and projections alone||Supportive|
|To have space to explore and express personal distress, restimulation, transference or counter-transference that may be brought up by the work||Administrative|
|To plan and utilize their personal and professional resources better||Administrative|
|To be pro-active rather than re-active||Administrative|
|To ensure quality of work||Administrative/Supportive|
Clinical supervision is seen as a sub-set of ‘educational’ supervision. I think it might be important that the three components of supervision are openly discussed and for some people, to have different supervisors for each component. It’s tough being open and honest with someone as a supervisor who may also be responsible for assessing performance and pay!
When I’m providing supervision, I really try to use the motivational model to help the therapist decide on:
(1) his or her values (what is important in his or her practice)
(2) various options and the consequences of those options
(3) how to reconcile ambivalence about making a choice as to which option is most aligned with his or her values as a therapist
This process requires extensive use of active listening skills, particularly levels of reflective listening. A potential area of conflict could be me trying to impose my own therapy values onto the person I’m supervising. I want to avoid this, because I believe it’s important for therapists to develop trust in their own internal radar.
I also provide loads of information leads. Sometimes supervision is simply about technical information.
Above all, supervision with me is confidential. I treat supervision as just another therapeutic session, subject to the same ethics as any other therapy. That is, I don’t expect to share content without the permission of the person. The only exception I make is the same exception I make clinically – personal safety and the safety of others.
For me, clinical supervision is all about the person being supervised. What he or she needs and wants from supervision is paramount. If ‘control’ is what supervision is about, it’s not really supervision, it’s management.
The ERIC digest has an older article Models of Clinical Supervision that explores a number of different models for supervision.
Victoria’s Mental Health Services has a good pdf document Clinical Supervision Guidelines as well as information in that link. Great to download the guidelines if you’re thinking of developing your own thoughts on the issues.
And the final one is a paper about ethics and supervision, suggesting that if Guidelines for Supervision are in their infancy, so too are ethics in supervision.
Teamwork and working with thoughts and beliefs.
Some therapists believe cognitive behavioural therapy (CBT) is ‘only’ for psychologists. Well, I’m not one of them. Frankly, if you are hoping to change ‘what people do’, you are using CBT…whether you’re doing it well or not – that’s another thing! (uhh.. that proviso holds for psychologists also)
What does it involve? It primarily involves identifying thoughts and beliefs, checking out the consequences of holding those beliefs, and providing the person you are working with some information about the implications of those beliefs. After this – it’s about doing something different to cement any belief change into place.
So, how does it all fit together? Well, in chronic pain it could work something like this…Anna attends her pain service. At intake, she is seen by three professionals – medical, functional and psychosocial (including work). She completes a set of questionnaires. At the end of the assessment, all her team sit together to discuss the aspects of her presentation that they feel are important. Using a common model of pain (biopsychosocial), her team review her questionnaires and develop a preliminary explanation (or hypothesis) for the development and maintenance of her current problems with pain. The team explains this model to Anna, who is able to confirm whether their findings ‘fit’ with her experience. She and the team agree that her main concerns are
- poor sleep,
- avoiding certain activities
- low activity level
She starts with the medical person to begin new medications, and then returns to see whether these have helped.
On this occasion she also sees the occupational therapist and psychologist to review (together) a model of chronic pain, and the impact on her life. Anna specifies her main concerns about her sleep, and it is hypothesised that she is not doing very much during the day, and she is very worried about her future. Her general fitness level is low and she is fearful of increasing her activity level.
The working hypothesis for the team is: Anna has chronic pain, she has developed anxiety about her pain, and is avoiding activities that she believes will increase her pain. As a result of this she is not doing very much, and her body is quite ‘wound up’. She is both deactivated (and has lost fitness), and has poor sleep (because she has not exercise much, and lies awake worrying).
Once her medications have been stabilised, Anna starts to see the occupational therapist, psychologist and physiotherapist to begin working on her functional goals.
The occupational therapist is interested in Anna’s daily activity pattern and the activities she most wants to pursue, including work; the physiotherapist is keen to establish a fitness programme to increase her cardiovascular fitness; while the psychologist intends to help Anna become aware of how her worrying has become a habit prior to going to sleep.
As a team they all agree that Anna is anxious about experiencing pain, is worried that when she has pain she ‘won’t cope’ (but is not fully aware of what she means by not coping), and has developed avoidance patterns and engages in safety behaviours that she has inadvertently developed to ‘keep herself safe’.
The physiotherapist encounters Anna’s automatic thought that ‘this is going to be too much for me’ when she starts to get on the bicycle. The physio gently encourages Anna to define what ‘too much’ would be – and reassures her that Anna has the skills to cope even when she is sore. At the same time, the physio starts teaching Anna diaphragmatic breathing, using a the word ‘relax’ as a cue word on the out breath. After the session the physio talks to the occupational therapist who sees Anna next about Anna’s concerns about coping.
The OT starts the session by developing a hierarchy of activities that Anna has been avoiding, going from ‘least concerned about’ to ‘most concerned about’. While doing this, she encourages Anna to identify what her automatic thoughts are, and what she thinks those thoughts mean. She encourages Anna to continue with a daily walk or cycle, and ends the session with a few minutes of diaphragmatic breathing using the cue word ‘relax’, and a posture-based relaxation. She gives Anna a notebook to record her walking or cycling, relaxation, and a copy of the posture-based relaxation.
Anna sees the psychologist last, and discusses the goals for the week. She and the psychologist talk through the meaning of anxiety and stress, and discuss the fight/flight/freeze response. The psychologist gives Anna a worksheet containing sentence stems about chronic pain, advises Anna on basic sleep hygiene and asks her to record her sleep in the diary. The psychologist also enquires about Anna’s exercise plan, and encourages Anna to work to get her heart rate to the target level.
In this example it’s hard to work out where the ‘psychology’ part begins and ends – and similarly where the OT and physio aspects begin and end.
This is teamwork, this is interdisciplinary, this is trust – and this is seamless service delivery.
Who benefits? Anna.