models

Pain model – helping to target change


In my recent post on behavioural approaches to pain management, I had a number of commentators ask why do it, why not focus on pain intensity, and aren’t I invalidating a person’s experience if I target a person’s response to their experience. Today’s post will explore some of these points.

I suppose my first point needs to distinguish between pain as an experience, and pain behaviour – or what we do when we experience pain. I like to use a pretty old “model” or diagram to help untangle these concepts. It’s drawn from Loeser’s “Onion ring” model, and he wrote about this way back in the early 1980’s. This is my interpretation of that way of thinking about the person experiencing pain. It’s not intended to represent Truth – but to help us to get our heads around an individual’s truth, or their experience. It’s one way to consider the factors we’ve learned are associated with human pain. It should be evaluated in terms of its utility and practical usefulness for a person experiencing pain, and for clinicians hoping to help them.

The “BIO”

Firstly, we have all the neurobiological processes involved in transmitting nociceptive information throughout the body. Much of this information never reaches conscious awareness – activity in nociceptors occurs all the time, and we have rapid reflexive responses to this such as blinking, shifting in a chair, swaying while standing and so on. A whole lot of neurobiological activity occurs as this information reaches conscious awareness – much of this activity occurs above the brainstem. In fact, if we look carefully at neurobiological activity, much of the reason we never notice reflex responses to nociception is because we have a pretty effective inhibitory system that’s operating constantly to limit how much nociceptive activity hits consciousness. That’s all part of cortical and brainstem (yeah – BRAIN) processes. If anyone learns neurobiology of pain and doesn’t include attention, motivation, emotion, expectations then they’re missing an enormous chunk of what nociception and pain are about.

Added to this neurobiological information are another whole bunch of physiological and hormonal responses – and these are incredibly complex and often omitted from our discussions. For example, men and women differ in their hormone production, and this means more women experience persistent pain, women have lower pain tolerance, and respond to nociceptive information more quickly and at lower thresholds than men.

Suffice to say, there are a whole bunch of biological processes that are integral to our experience of pain and to nociceptive transmission, transduction and perception. So if anyone should suggest that a “biopsychosocial” model of pain does not include BIO – go wash your mouth out please.

Pain-the-experience

The next aspect of pain that Loeser included was “pain-the-experience” – the subjective, personal, unshareable “what it is like to experience pain” part. This encompasses the qualia – the sensory qualities of pain, and includes intensity and location. Pain is always experienced as having a negative or aversive quality, so we know that the urge to avoid or take action to reduce, and indeed our tendency to attend to this experience is part of a human experience of pain. Note that Loeser (and I) don’t include appraisal at this point! In other words, this is the “ouch” that a baby feels when we perform a Guthrie heel prick test. It’s that moment when scalding coffee hits your lap, before you’ve realised you’ve spilled your coffee.

But just to complicate things here – unless we’re newborns, we’re always aware of context and pretty much once we learn language, we’re interpreting when/where/how/why events are happening. This means that factors such as expectations, past learning, predictions we make about “what next” always inform “pain-the-experience”. Even before we’re consciously aware of these influences! So technically, as soon as we recognise “ouch” we’re already invoking a whole bunch of higher cortical processes into our experience. This matters because pain is a conscious experience, and requires perception before it can be experienced.

Judgement or appraisal

The next “ring” of Loeser’s model was called “suffering” – I’ve translated this into a cognitive process of “appraisal” because while pain is inherently tainted with negative emotional valence and a motivational urge to avoid, it’s also possible to view our experience of pain in different ways. Some commonplace examples are the jab from a vaccination – many of us will welcome that nociceptive input, and judge the pain to be negligible. Others who may be less comfortable with a vaccination might view it more negatively and be more aware of that pain. People who run or train in a gym might appraise the pain from working hard “feel the burn” as a sign that they’ve done enough to make performance gains. And some of us who live with persistent pain such as fibromyalgia might notice pain and consider it to be “just a nuisance”.

Suffering is an interesting concept, and I prefer to take Erik Cassel’s definition of it: suffering refers to the loss of a sense of self. A paper cut typically doesn’t lead to a loss of sense of self, while low back pain that remains for many months might be far more likely to erode that sense of “who I am and what I can do”.

Judgements and appraisals are influenced by a whole lot of factors – socio-cultural norms (I’m in a rugby-mad country, if a rugby player experiences pain on the field, he or she may well grit teeth and keep going, believing that it’s not OK to “give in” to pain – the appraisal might be “this isn’t so bad, I can still keep going”. Socio-cultural norms are often implicit – we absorb them effortlessly within our own cultural context, and we’re quite capable of holding different implicit norms depending on our current proximity to our social group. Consider the rugby player who will brush off an on-the-field injury but when getting a splinter might feel a little sick. The meanings we attribute to our pain influence how willing we are to go with them – tattoos and body piercings and body suspensions are really good examples of times when we’re OK to experience pain in the pursuit of something else, similarly post-surgical pain after joint arthroplasty.

When appraisals are unhelpful is when we get tripped up. When a person holds an inaccurate understanding of what’s happening – thinking, perhaps, that this back pain is a sign of cancer metastasising, or the end of a career as a sportsman, or an indication of some dire outcome, then a couple of things happen. Firstly, negative emotions are likely to rise, along with sympathetic arousal (the two systems are linked in the experience of pain), and then what we do about pain also begin to turn to short-term over long-term outcomes.

Pain behaviours

Pain behaviours are what we do when we experience pain, and they’re shaped both by evolution and by socio-cultural norms, as well as what we think is going on. I wrote about pain behaviour recently – click

Pain behaviours are the only part of “what it is like to experience pain” that we can observe.

Let me say that again – what we do about pain is the only part of the pain experience that a person who is NOT The Person In Pain that we can share.

Pain behaviour includes everything a person does and says in relation to their pain, both reflexive and automatic actions that we’re not aware of, as well as those we are aware of. Some of the behaviours we do are reflex responses (blinking and tearing up), some of them are not. Some of them are well-learned – we’ve been doing them since we were tiny kids. Others are things we’ve learned to do, perhaps on the advice of someone else, or because we’ve observed someone else, or because we think it might help or it’s worked once before.

The thing is – pain behaviours are malleable. They can and do change. Again, read my earlier post on how pain behaviours can be changed, and know that just because a behaviour has changed, the person’s experience of pain may not. In other words, while I move pretty normally, and to many onlookers I don’t appear to have pain – I still do.

Social context

I’ve already alluded to the influence of contextual factors. Things we’re aware of – prevailing attitudes in our immediate social group, our community, our spouse, our treatment providers. Things we’re often less aware – of implicit attitudes about gender, ethnicity, socio-economic status, supposed pain mechanisms, visibility of tissue damage and so on. And we are ALL influenced by these implicit socially constructed attitudes and beliefs, people with pain and their clinicians and their families and their communities….

I often use this way of exploring factors involved in why a person is presenting in this way at this time, and what might be done to reduce distress and disability. I might package the conversation in various ways – perhaps more complex if I expand on some aspects, perhaps less so if the person doesn’t want or need to explore something (often this is the neurobiological part). While it’s imperfect remember that the purpose of a model like this is contextual. I am not hoping to represent Truth as a universal law about “how pain works”. I AM hoping to explore useful elements for a particular purpose. One purpose might be to demonstrate that emotions and appraisals influence pain behaviour. Another might be to introduce medical students to the complex factors that might be involved in their interpretation of a patient’s distress. And another to help someone understand why he avoids a movement in one context but not in another. And even another might be to help someone know why she has such a panicky feeling when she’s in the middle of a flare-up.

As a pragmatist, and basing my practice on approaches that might help this person achieve a specific something in this moment, I use models like these to build therapeutic alliance, to enable the person to be willing to play with new ways of being, and to help them recognise that the target for change might not be what they initially think is relevant.

Loeser, JD. (1980). Perspectives on pain. In P. Turner (Ed.), Clinical Pharmay & Therapeutics (pp. 313-316). London: Macmillan.

Loeser, JD. (1982). Concepts of pain. In M. Stanton-Hicks & R. Boas (Eds.), Chronic low back pain (pp. 145-148). New York: Raven Press.

Clinical reasoning models: what’s wrong with them?


I’ve been interested in clinical reasoning and models used in clinical reasoning for quite some time. Occupational therapy has several models, including the “occupational therapy problem solving process” by Lela Llorens, the Model of Human Occupation by Gary Kielhofner, and the Canadian Model of Occupational Performance by Polatajko, Townsend and Craik in 2007. All of these models were designed to support occupational therapy clinical reasoning processes, and to capture the essence of what occupational therapy is about.

When it comes to pain rehabilitation, I’ve found the occupational therapy models a little lacking in specificity for my clinical reasoning. I’ve also noticed similar problems with proposed clinical reasoning models for physiotherapy when considering pain.

Here’s the thing: if pain involves so many factors (call them biopsychosocial for want of a better all-encompassing term), and we don’t know which factors are relevant for this person at this time, clinical reasoning in pain rehabilitation is complex. Why? Well the problem with pain is that it’s full of ambiguity. Not so much for the person experiencing them, but certainly for the clinician trying to help.

Bear with me a minute. To me, clinical reasoning models help shape the factors we include and those we omit.

In writing that sentence I realise I’m assuming something crucial: that models are designed to help us predict and control what’s going on. Is that the purpose of a model? I quickly did a search and found this definition: “In science, a model is a representation of an idea, an object or even a process or a system that is used to describe and explain phenomena that cannot be experienced directly. Models are central to what scientists do, both in their research as well as when communicating their explanations… Models are a mentally visual way of linking theory with experiment, and they guide research by being simplified representations of an imagined reality that enable predictions to be developed and tested by experiment.” It’s from here.

OK, so in clinical reasoning what utility does a model need? I think a model needs to generate hypotheses that explain the unique presentation of this person, their problems, at this time. A nomothetic representation of what might be going on for this unique person.

Occupational therapists and physiotherapists, and probably psychologists, are all concerned less about impairment (that’s damage or dysfunction at the body structure level) than we are about the impact this has on functional limitations and on participation. This doesn’t mean we’re not interested in impairment, but our focus is much more likely to be on “and what impact does that have on what you need and want to do”. Occupational therapists, in particular, are concerned about “and how does this affect the way you participate in our world”.

But if we look at clinical reasoning models in our various professions I think there are some gaps. I don’t think our models invite us to generate hypotheses because the various clusters of information don’t seem to link together in a terribly coherent way. Yet – with all the information around us, there are some causal (or bidirectional) relationships we can consider.

For example, we know that if someone is very fearful of their pain, they’re likely to describe elevated physiological arousal, and they’re not as inclined to engage in movements they believe will exacerbate their pain.

A line of reasoning goes from Fear -> Physiological arousal and Fear -> Avoidance.

This simple set of hypotheses generates some ideas about what might help. Firstly we’d test the presence of fear – is it just happening in this moment, or is it something that’s been present consistently? Mostly we ask the person, but we could use a questionnaire measure of fear of pain. We could also test for physiological arousal – is this present? How do we know? We could use various biofeedback devices, or we could simply ask (or use a questionnaire). And of course we can test for fear-avoidance as a combined construct via questionnaire and/or behavioural testing.

This set of steps really just determines whether our hypotheses are present, so now we need to generate some treatments. In this case, we also draw on research and think about providing information – this, we hypothesise, should reduce reported fear. So we embark on some explanations about what’s going on – and we should see a reduction of fear on a measure of pain-related fear. But perhaps not on avoidance because we know that behaviour change requires more than simply information. We might also help the person down-regulate their excitable nervous system, reducing that “fear -> arousal” relationship. And finally we might begin doing some exposure work which acts on reducing fear in the presence of doing something scary (movements) and so reduce the relationship between fear -> avoidance.

What the example above shows us is what might happen once we’ve identified some potential phenomena that may be present. What it doesn’t show, and something I struggle to find in many clinical reasoning models, is how clinicians identify those phenomena. Why would someone think to ask about fear of pain? Especially if we believe that our job is to help reduce pain and pain’s the only reason the person isn’t doing things. And even more – if we think our job is to deal with “physical” and fail to recognise the relationship between “physical” and “feelings, beliefs”.

You see, I think broad “groups of factors to consider” belongs in the assessment, but we need something more tangible when formulating an individualised explanation. We need to be generating hypotheses about how these various factors interact and lead to a presentation – and while much of this will be conjecture initially, by generating various hypotheses we can then go on to test them – and ultimately establish the priorities for treatment in collaboration with the person. That’s much easier to do when we’ve fleshed out why the person isn’t able to do what’s important to them, and we’ve synthesised all the known factors in some explanatory model.

Is this complex? Yes – but who said it had to be easy? This is why we do the work we do, because it’s complex and “common sense” doesn’t cut it. And if our various professions really want to adopt a sociopsychobiological framework for pain, maybe our clinical reasoning models need to synthesise all these factors in some coherent way rather than simply plonking the groups of factors down without integrating what’s known about the relationships between variables from different domains.

Wacker, J. G. (1998). A definition of theory: research guidelines for different theory-building research methods in operations management. Journal of Operations Management, 16(4), 361-385.

Yazdani, S., Hosseinzadeh, M., & Hosseini, F. (2017). Models of clinical reasoning with a focus on general practice: A critical review. Journal of advances in medical education & professionalism, 5(4), 177-184.

Musings on theory and clinical work


ResearchBlogging.org
This muse won’t be quite as lengthy as my last rant on occupational therapy and science, I promise! At the same time, it’s on a similar theme – and touches also on my post about ‘back to the basics’ where I discussed the recent review of pain contracts by ACC in New Zealand.  This review criticised the number of pain intervention services (eg injection therapies) and functional reactivation programmes that are provided without due regard to integrating the psychosocial along with the biomedical.  I suggested that perhaps providers need to be ‘risk profiled’ as well as claimants, because some of the behaviour seen in providers is likely to disregard high risk psychosocial factors and reinforce disability.

If clinicians are to be something other than ‘technicians’ applying a process to their patients, they (we) need to understand the concepts lying behind an intervention.  At the same time, we also need to be able to understand when an intervention isn’t likely to succeed, and when a variation on an intervention might suit better.  To do this requires effective clinical reasoning – aha! a theme!  I’ve hammered on a bit about clinical reasoning because it underpins the WHY we might choose to use one intervention over an other.  Clinical reasoning implies working backwards from what is evident in the patient’s presentation to hypothesise about how those features might occur.  In other words, developing a clinical theory to explain how and why the person is showing this behaviour.

Clinical reasoning can be quite straightforward in many settings.  After all, building on the knowledge of centuries, clinicians know enough about bone healing to align a broken bone, stabilise it, and wait for it to heal without doing too much thinking about it.  (Pssst! Don’t tell the orthopaedic surgeons this!)  Similarly, in an acute hospital setting, some fairly simple reasoning is needed to establish whether a person can get on and off the toilet with a raised toilet seat and then issue one if need be!  However, clinical reasoning can be (and usually is) much more complex than this.  Depending on their professional orientation, clinicians working with an acute fracture might ask why the person broke the bone, what the implications of that immobilised limb might be on occupations, might be considering the need for supports at home, might be monitoring for signs of shock – and the point is, these further interventions depend entirely on the theory-base of the clinicians working with that person.

Even in the case of someone needing a raised toilet seat in order to be discharged safely home, the clinical reasoning behind that simple intervention is not just about the biomechanics of getting on and off the toilet!  It could also be asking why the person has trouble standing up and keeping balanced, how the person might cope at night without lighting, whether the person can (or does) ask for help and so on.  Without having a good theoretical framework on which to base information collection, and a similarly effective way to organise that information, the clinician might as well simply issue a raised toilet seat and be done with it!

I’ve deliberately used simple examples to illustrate so-called simple clinical reasoning.  Now lets consider more complex examples.

Firstly, an analogy.  If I wear a set of glasses that occlude my vision on the left hand side of each visual field, I can still see. What I can see is limited, and I need to move my head around to scan the whole of my environment, but I can see.  After a while wearing these glasses, perhaps a week or so, finding my way around becomes easier, and in fact I’d have trouble after just another week of wearing the glasses, adjusting to ‘normal’ vision.  The world would look ‘normal’ to me even though part of my visual field is blocked.  New items appearing on the left side of my field of vision could suddenly ‘pop’ out of nowhere, and unless I know I’ve got those glasses on, I could be quite unaware of the amount of visual information I’m missing.

This is exactly what happens when a professional dons a single theoretical perspective.  I’m guessing we can all recall the first years of becoming a professional, and how strange adopting that new ‘persona’ felt.  After a while, though, it becomes familiar and we hardly notice it.  Then along comes new research, new theory, new models and new interventions.  The world gets a little shaken up!  We either integrate this new information, or we work hard to ignore it. ‘High risk’ clinicians are, IMHO, those who fail to recognise the contribution of information from outside their existing frame of reference. It’s my opinion that these clinicians can and should be identified, and either helped to integrate the new knowledge – or not allowed to practice in a field like pain management where the contribution of information obtained from so many fields is critical.

Bringing this back to clinical reality, if we are unaware of the theoretical models or even the professional models we use, we can be completely stumped when a new situation arises, or when a new piece of information is brought to light – a bit like that object coming into view on the left field of vision when I’m wearing those glasses!  By taking the glasses off, opening up the whole visual field, we can be much more aware of the fact that we do have constraints on what we can see, and if we look more broadly we can identify areas we want to look at in more detail.

OK, enough with the analogy.  Some clinicians scoff when I talk about my interest in science, theory, models and the process of clinical reasoning.  I think it’s vital.  Without articulating why a certain intervention is recommended, I think it’s impossible to distinguish between following a protocol as an assistant and being a versatile and adaptive clinician.  An assistant may not know how a process works, just that if (a) and (b) are following in a certain order, (c) will ensue.  If (g) or (h) are present, an assistant won’t know how to respond.  A good clinician knows that people may present with the same behaviour, but the underlying factors influencing that behaviour could be very different.  For example, someone saying that he or she can’t sleep and wakes often might be due to pain, a natural wakening during normal stages of sleep, having chronic sinus problems, low mood, anxiety – or even the effects of having a new baby in the house!  The work of clinical reasoning doesn’t start with simply ‘identifying the problem’ and then solving it: it begins with the way in which the clinician views the situation and the contributing factors.  If we’re not careful, even as experienced clinicians, we can jump to conclusions or simply ‘assume’ that the clinical problem is the one with which we’re most familiar, or the one that springs to mind the most easily.

It takes a lot of effort to avoid prematurely deciding on ‘what the problem is’ during a clinical intervention.  Being aware of our cognitive limitations, noticing our assumptions and broadening our view to include searching for as many different pieces of information as we can helps to prevent clinicians from working from a recipe – but it’s also hard work.

I’m referring back to Vertue and Haig’s paper on Abductive Theory of Method in clinical reasoning as the basis for today’s post. Read it if you’re keen on science, models, theory and clinical reasoning, and let me know what you think.

Frances M. Vertue, Brian D. Haig (2008). An abductive perspective on clinical reasoning and case formulation Journal of Clinical Psychology, 64 (9), 1046-1068 DOI: 10.1002/jclp.20504

Small (but *long*) rant on occupational therapy & science


ResearchBlogging.org
Hands up the occupational therapists who like statistics!  Thought not.

What about those who read journal articles comparing one treatment with another?  Use a treatment model consistently – or use a set of hypotheses and test to see which ones apply to the person we’re working with? Hmmm….  Are occupational therapists ‘epistemiphobic[1]’? or simply naive about science.

I recently read an assignment on clinical reasoning written by a very competent and educated occupational therapy graduate.  In it the views of Kuhn, cited in Mattingly and Fleming were described where ‘clinical reasoning within a biomedical frame is like puzzle solving, in that a clearly identifiable correct answer exists (e.g., a pathology, a cluster of physiologic deficits), and the player’s task is to find that answer.’ The argument continued that ‘Occupational Therapists in pain management often find themselves reasoning their work in a scientific and biomedical framework due to the nature of their work environments. This unfortunately often discredits the more difficult unspoken things that are done by the Occupational Therapist to the more recognisable and clearly defined instances that medical terms provide.’

My problem with the statements in this are that it assumes that science ‘discredits’ the ‘difficult and unspoken’ things done by occupational therapists – that somehow, occupational therapy is too complex for ‘science’ to unravel and understand.  Firstly this ignores the complexity of scientific methods such as constructivism, and secondly it suggests that what occupational therapists do is so complicated and unrepresented that no-one truly understands it. I also disagree that the prevailing model within pain management is a biomedical one – it’s clearly accepted that a biopsychosocial model is the one that most of the researchers and clinicians now accept. (Head here for one of the most popular books on pain management...no I’m not advertising OK?!)

I’m going to deal with the first point, that occupational therapists have a limited understanding of science, and as a result misinterpret the multiple ways in which society, culture and indeed health care, has been built on the scientific method.  Then I want to turn to the suggestion that what occupational therapists do within treatment is so incredibly complex and individualised that it can’t be subjected to the kind of systematic scrutiny that other health professions have used, with success.

In the history of health care over the past 100 or so years, there has been a swing from humanism[2] toward empiricist[3] epistemology[4] and more recently, back again towards a constructivist[5] view of what makes up a ‘healthy’ individual.

This has been paralleled within the development of occupational therapy – from the Adlerian view of humans as being essentially self-correcting and requiring simply a context and ‘activity’ within which to flourish (Adler, 1931), through to the reductionist biomedical view of humans as an assemblage of body parts that can be pieced together using artificial limbs and principles of biomechanics (for example, as described by Ice, 2005).  As a reversal of this, the constructivist point of view has focused on the lived experience of individuals, rejecting the idea that data that is grouped together can truly represent what is true for any one person (Toombs, 1995).

Today, it’s not always clear, but plurality in how people define and reach wellbeing, especially while self managing chronic health conditions such as diabetes, rheumatoid conditions and chronic pain, is much more broadly defined than ‘the absence of disease’.  The WHO definition of health was, in my training in the early 1980’s, held up as an ideal rather than a reality.  Today, possibly as a response to the rise of chronic health conditions, the outcomes of health interventions are measured as often in terms of ‘quality of life’ and ‘disability’ than in complete cure.   Incorporating a ‘strengths’ approach within mental health (e.g. Cowger, 1997), looking at resilience within positive psychology (Seligman, 2008), and looking at fostering supported self management (Bycroft & Tracey, 2006), are not just passing fancies – they all have a sizable literature, and one that not only draws upon empirical science including randomized controlled trials, but also builds upon ‘the lived experience’ of individuals in all their complexity.

Science can often get a bad rap in the media.  Members of the public criticize scientists for being equivocal about results, for crying wolf over what may be harmful in one study and helpful in another. It’s not surprising that faith in what science can offer in health is somewhat low.

But occupational therapists are not the ‘general public’. Occupational therapists work within a health system that, for the most part, relies upon considered opinion based on fact.  Cold hard facts, often in the form of cost effectiveness, mean that well-designed scientific studies are needed to demonstrate that treatments are worth paying for.  This makes sense to me – I pay taxes, and I attend for treatment.  I’d much rather know that the treatments my money is spent on are known to work, and for whom; and I’d really like to know that when I need treatment, the options I’m given have data supporting their use rather than that old paternalist attitude of ‘the doctor knows best’.

I think science is misunderstood by many occupational therapists.  It’s seen as something removed from the daily reality of clinical life because it involves strange things like ‘control groups’ and ‘statistics’ and experiments, things that clinicians in everyday practice really don’t often do.  Science might not have even been part of some occupational therapists schooling, either before professional training or even as part of undergraduate training.  Girls and women are found to be fearful of science and mathematics as they go through school (e.g. Stipek, & Granlinski, 1991), particularly higher levels of schooling.  If these attitudes and beliefs continue in senior occupational therapy professionals and educators, it’s likely that undergraduate and newly graduating therapists will remain unaware of the place of science as part of the development of knowledge about our world and cultures.

Maybe it’s time occupational therapists took a second look at ‘science’.

Science simply means the ‘systematic study’ of phenomena to identify how it works, whether it will happen again, how it happened, where it happened, how similar or dissimilar that phenomenon was to another one – and so on.  Most of us are familiar with the ‘hypothetic-deductive’ process of experimenting to find out whether treatment X influences outcome Y.  This represents only one approach to the scientific study of phenomena.  There is more than one way to ‘do science’.  Here’s a very recent discussion about a definition of science.

Most of what we accept as ‘known’ today has developed as the result of years of serendipitous and systematic discoveries.  Serendipitous because we can all probably think of at least one discovery that was simply ‘a happy accident’ – think of Fleming and penicillin.  Systematic because once that finding was made, a concerted effort was made to understand what had happened, and to find out how to do it again – and explore the properties that caused such excitement in the beginning!

The view of science that I take is based on combining both aspects of scientific discovery.  The first is to identify something unusual that occurs – and then to see if it happens again.  Once is simply an aberration, twice may be coincidence, while three or more times starts to look seriously interesting. An example in occupational therapy practice might be to notice that several people with chronic pain describe being very reluctant to do their grocery shopping.  While in one or two people, this might be simply an area to work through to help them achieve independence, if it occurs in many people, especially in people with quite different pain presentations and durations, it might point to something worth investigating.  In the language of science, this is called ‘a phenomenon’, and if it’s demonstrated to be present in many people of different pain presentations and in different cities, then it could be called a ‘robust’ phenomenon.

It’s this first ‘aha!’ experience that is one of the most creative and serendipitous aspects of science – but that creativity need not stop there.  First of all, it’s really important to clearly and fully describe the phenomenon – using any manner of methods to identify who demonstrates it, how it’s portrayed, what settings it appears in, whether it’s simply in large supermarkets or maybe also in small convenience stores, whether there are any relationships between this problem with grocery shopping and any other pain-related phenomenon such as pain-related anxiety and avoidance (fear-avoidance).

The second part is to systematically study to understand how and why that phenomenon occurs. This involves painstaking hypothesis generation and testing, and the hypothesis generation part involves asking multiple ‘why’ questions, testing out with many experiments whether the predictions of that explanation hold true.  It also means a lot of disappointment as a favourite explanation turns out to be inaccurate, or incorrect.   The ‘experiments’ can be good old hypothetico-deductive ones, or more broadly-generated constructivist ones.  And to do this careful examination of evidence for and against any particular explanation means controlling for outside influences and chance.  This is whe re the statistics and other horrid mathematical things can come in handy because they allow us to factor ‘in’ or ‘out’ the amount of variability and trust we want to put into our experiments.  But this approach isn’t the only way – we can also use qualitative methods such as intensive description to examine a phenomenon, but even a constructivist approach to science uses inference to draw conclusions from one situation to help us consider and hopefully understand another situation.

So, science is about being systematic, recognising that each of us views the world slightly differently – but underneath all that, there are some commonalities at some point that we can recognise and then apply to another, similar situation (or by comparing what is dissimilar, use that information to inform a completely different situation).

I was with a group of therapists recently, and mentioned the word ‘model’ to them – to hear them talk, models are irrelevant to the ‘real’ day-to-day work of an occupational therapist.  Who’s got time to do all that reasoning and thinking in the business of helping people do things differently?  Well, whether you are aware of a model or not, everything we do especially within a therapeutic context, relies on the model we use. Models are simply a framework that describes more or less ‘how things work’, or how concepts hang together.  The good thing about a model is how easily it can organise how we gather information and what information is thought to be relevant or irrelevant.  A model is more or less helpful, depending on how well it works to explain the phenomenon we see.  The more accurate a model is, the better it will explain how and why a phenomenon occurs.

When we’re being educated as therapists, we spend time learning about various models, and for the more theoretical amongst us, models bring to life the various ways we can learn to view a ‘problem’.  Occupational therapists are famed for being ‘problem solvers’ because we learn to view a ‘problem’ as something that can be solved or ‘got around’.  Initially it’s not easy to solve various problems, but as we gain experience, see more problems, learn what works and what doesn’t work, we become much more capable of seeing ways to solve problems.  But as we do this, the visibility of our reasoning can slip behind this wonderful thing called ‘intuition’.  Intuition simply means that ‘we don’t know how we do it, but we come up with the right answer’ – or as a psychology lecturer once said, ‘intuition is overlearned skill’. We’ve got to the point where we are unaware of all that background reasoning and those assumptions that we have made because we’ve done it so often.

To give an example: we don’t think much about how we walk, or at least most of us don’t.  By the time we’re adults, walking is ‘intuitive’ – we just do it.  But there was a time when we were learning to walk, and it took all of our attention and we made a lot of mistakes and only after a couple of years did we actually ‘get’ how to walk.  Similarly, for most of us, driving the car is now pretty simple – we ‘intuitively’ know when to change gear, when to apply brakes, when to turn the wheel – but we probably all remember what it was like to learn how to drive!

Why am I raving about this? Well, the models we use in occupational therapy (& indeed in any therapy) initially feel quite difficult, require a lot of thought and we need to concentrate to ensure we collect information on all the relevant areas in that model. The models are based on things we ‘know’ about the world – scientific studies that verify the relationships that we recognise within that model.  For example, if we’re using a biomechanical model, we base this on the physics of movement – lever arms, fulcrum, equal and opposite forces.  We rarely go back and re-test the physics because they’re ‘common sense’.  Ermm… maybe they are now – but there was a time when humans didn’t know this and had to learn it.  So when we’re faced with a problem that appears to be solved using a biomechanical solution, we ‘intuitively’ solve it – but our intuition is based on the accumulated wisdom of all those people who did set out and test the laws of physics.  We just quickly jump to that conclusion because we don’t need to check out those laws any more.

The problem is when we try to use a biomechanical model to solve a problem that isn’t fully understood using a biomechanical model.  A good example might be manual handling.  We have assumed that the problem with back pain is essentially that we lift using poor biomechanics, placing additional loads on structures that shouldn’t be placed under such strain.  The solution seems clear – let’s all learn how to lift using ‘proper’ biomechanics and all will be well.  Sorry – that doesn’t work.

The problem of sore backs is not fully explained by a biomechanical model, but because to many therapists it seems ‘common sense’, other solutions don’t get a look-in. It’s been the work of scientific endeavour that has expanded the range of factors that are known to influence back pain (and more especially disability from back pain) that has started to provide some explanations for how and why some people have trouble managing their pain.  And the solutions derived from this research are not ‘intuitive’ to many therapists yet.  They’re still being examined, and they still need expanding.  But if we’re scientifically illiterate, feel afraid of reading scientific articles, rely instead on ‘intuition’ and either don’t measure outcomes or rely on inaccurate measures of outcome, we might continue to believe the biomechanical model is accurate.

Is occupational therapy so complex that what it does can’t be examined using science? I don’t think so.  If it is, then we’re saying that social systems, cognition, emotions, politics, neuroanatomy and physiology and perception are all much more simple than making a cup of tea in the morning when we get up.   Hmmm.  I don’t think so.  It’s more about looking at aspects of that activity in the light of various models (scientifically validated/tested hypotheses) and coming up with an explanation that can explain the most of what we see, with the least number of assumptions.  And while that might be quite distant from the day to day work of a therapist drafting housing alterations or a therapist establishing whether a person is safe to leave the mental health services and manage alone, the work that both of those therapists does uses models – and relies on assumptions that those models inherit.  To ignore the reality that we simplify our worlds so we can get our heads around them and to call it something woolly like ‘intuition’ does the cognitive work we do a disservice.

Is there anything wrong with simplifying the world? No – psychologists have been doing it for at least a century! The cognitive behavioural model is good example of a simple model that explains part of an individual’s behaviour.  It doesn’t explain everything, but it does provide some useful assumptions that help us help another person make changes.  Put together with other models from within psychology, and others from other disciplines, it starts to explain something about how people ‘tick’.  Maybe that’s the best that we can do at this point in time to understand each other.

So… should occupational therapists know ‘science’ – oh yes! both quantitative and qualitative methods too.  And probably some philosophy, and certainly lots of theory-building, and probably more psychology and sociology and biomechanics and anatomy and physiology.  Why not?!! At the very least occupational therapists should have some idea that what they’re doing is not ‘simply intuition’ nor ‘common sense’, that they do hold assumptions about how the world works when they view a problem, and their solutions are based on those mental models that we’ve learned.  So science is integral to how we do what we do.  Let’s not be afraid of science, let’s not think it’s irrelevant – let’s honour it and celebrate it and get on and DO IT!

 


[1] Epistimi – Greek word for ‘science’ or ‘knowing’, phobos – Greek word for ‘fear’ – a term I coined!

 

[2] Humanism – humanism is defined as a doctrine which seeks to account for the specificity, uniqueness and dignity of human life (retrieved from http://plato.stanford.edu/entries/jaspers/#PhilRel 7 September 2009 at 9.34am).  Occupational therapy is considered a strongly humanist profession.

[3] Empiricism – this school of philosophy claims that what we experience through our sense is the ultimate source of all our concepts and knowledge.  In other words, unless someone can show us something that is able to be touched, examined or measured, it cannot be known.  By contrast, a rationalist viewpoint suggests that we already know about things, or we can deduce things from what we do know, and it’s a matter of simply uncovering these known things through logic and reasoning. (retrieved from http://plato.stanford.edu/entries/rationalism-empiricism/ 7 September at 9.43am)

[4] Epistemology – the branch of philosophy devoted to studying the nature, sources and limits of knowledge (retrieved from http://plato.stanford.edu/entries/rationalism-empiricism/ 7 September at 9.43am)

[5] Constructivism – Constructivism states that our knowledge about what the world is entirely dependent on the meaning we as individuals make of what we perceive within our cultural context. In health constructivists assert that to call a condition a disease is to make a judgment that someone in that condition is undergoing a specific kind of harm that we explain in terms of bodily processes. But the bodily processes are not objectively malfunctioning; rather, they are merely judged by us to be unusual or abnormal because they depart from some shared, usually culturally specific, conception of human nature. (retrieved from http://plato.stanford.edu/entries/health-disease/#ObjCon 7 September 2009 at 9.48am)

References

Bycroft, J., Tracey, J (2006). Self-management support: A win-win solution for the 21st century, NZ Family Physician, 33(4), 243-248

Cowger, C. (1997). Assessing client’s strengths: Assessment for client empowerment. In D. Saleebey (Ed.), The strengths perspective in social work practice (2nd ed., pp. 59-73). White Plains, NY: Longman.

Ice, GH., (2005). Biological anthropology and aging. Journal of Cross-Cultural Gerontology, 20(2) 87-90

Mattingly, C. & Fleming, M.H. (1994). Clinical reasoning: Forms of inquiry in a therapeutic practice. Philadelphia: F.A. Davis Co. U.S.A.

Seligman, M.(2008). Positive Health, Applied Psychology: An International Review, 57, 3–18

Stipek, D, Granlinski, H (1991) Gender Differences in Children’s Achievement-Related Beliefs and Emotional Responses to Success and Failure in Mathematics, Journal of Educational Psychology , 83 (3) pp. 361-71.

Toombs, S K., (1995) The lived experience of disability. Human Studies, 18(1) 9-23

Ice, G. (2005). Biological anthropology and aging Journal of Cross-Cultural Gerontology, 20 (2), 87-90 DOI: 10.1007/s10823-005-9084-6

Thinking about thinking…


For a long time I thought everyone thought about what they think about, how they think about it, and what their thinking concluded – now I know that some people never do this and live on simply following the rules (and probably having a fun and relaxed time of it!).  I, on the other hand, have always spent time at the end of the day thinking about my thoughts and what they mean and how I come up with them.  The technical term for this is ‘metacognition’, or ‘thinking about thinking’, and it’s a strategy that can be really useful in cognitive therapy as well as pain management – and even more useful in your professional work as a therapist.

I started writing this post after reading this from the Skeptical Methodologist… in it The Skeptical Methodologist points out that although ‘…the scientific method as we know it from the enlightenment is a sound way to find truth about our world, we must always remember that the evidence we produce from any one experiment is only as good as the assumptions that went into it.’

What this means, is that if we don’t include our assumptions in any experimental method, we won’t be able to seriously critique our findings – our findings may only hold true in certain circumstances.  This doesn’t detract from the truth of those findings in those circumstances, but it does mean that we can’t generalise without risking making errors.  For more about this, read Ben Goldman’s article on How Myths Are Made.

If we’re unaware of our assumptions we may never look at our findings in the light of them – and this error is one I’m especially concerned about when I see exclusive reliance on  ‘self reflection’ and peer review of practice.

After all, if we have learned our professional skills from others within the profession, and even our professional peers haven’t had a broad or general knowledge of other approaches to treatment (or even to science), then we’re unlikely to know the assumptions that we hold. Sometimes it takes an ‘outsider’ or an interaction with another model or approach to help us look at what we assume is a ‘given’.  This can be challenging and sometimes disheartening – but can aid us in generating new and different ways of viewing our practice.  Think of general systems theory which came originally from engineering and has now influenced almost all the sciences including biology, chemistry, physics, sociology, psychology and health care!

Wikipedia states that: ‘Metacognition refers to a level of thinking that involves active control over the process of thinking that is used in learning situations. Planning the way to approach a learning task, monitoring comprehension, and evaluating the progress towards the completion of a task: these are skills that are metacognitive in their nature. Similarly, maintaining motivation to see a task to completion is also a metacognitive skill. The ability to become aware of distracting stimuli – both internal and external – and sustain effort over time also involves metacognitive or executive functions.’

Metacognitive monitoring and metacognitive control of emotional states have been suggested as a way for people with mood disorders and other behavioural disorders to take control of their illness.  The suggestion is that the person monitors his/her emotional state, applies a label to it, compares it to what they would really like to feel, and then takes action to make the current emotional state become closer to the goal state.  Another approach is to become aware of the thoughts – label them, recognise the emotions – then choose what actions to take that will ensure what is important (eg a value) is done.  This is one of the underlying strategies of ACT.

So, what does metacognition look like?

For me, it means forever asking questions about ‘why’.  Why do I take notice of this and this and this?  Why does that strategy work here but not here?  It means I become aware of my thoughts – then I can check my beliefs, and the foundations of those beliefs, test them for helpfulness (and accuracy!).   I can match those thoughs against whether they are helping me achieve what I want in my life, and often whether they’re even accurate.

In pain management, it can mean helping patients identify their thoughts – and especially, their anxious worrying or ruminating.  Metacognitive theory suggests that this approach developes into ‘cognitive attentional syndrome’ where the thinking actually focuses attention on emotional content and distracts from active coping.   ‘This pattern consists of worry, rumination, fixation of attention on threat, and coping behaviours that the person believes are helpful but many of which backfire and keep emotional problems going.’ Treating these problems using metacognitive therapy involves ‘helping patients develop new ways of controlling their attention, new ways of relating to negative thoughts and beliefs, and by modifying metacognitive beliefs that give rise to unhelpful thinking patterns.’ Sound familiar?

In other words, if we can help people become aware of what they’re thinking and that it’s unhelpful and probably based on unaccurate beliefs (and distinct from who they are), and we’re able to engage them in activities that are much more interesting and involving, they’ll be able to reorient themselves into a life they want to live.

But before we start employing metacognitive therapy in pain management, how about spending about 10 minutes after doing an assessment or a treatment – and thinking about your thinking?  What goes through your mind while you’re working with that person?  What are your assumptions?  Check out whether you’re assuming things on the basis of gender, age, ethnicity, occupation, even diagnosis.  You might be surprised at what you find out.

Don’t forget, I post most days during the week, love coments (even when they don’t agree with me!) and will reply!  If you want to come back, just bookmark – or you can subscribe using the RSS feed link at the top of the page. Hope you have a good week!

Some theory – and how we can put it into practice


Before we start on cognitive behavioural therapy, we need to know what we’re on about – for me in pain management, CBT assumes:

  • that people are capable of change,
  • can accept self responsibility for their actions,
  • that what we think and believe about a situation can affect our emotions and responses, and
  • that we can implement a whole range of strategies that can make a difference to life

We may not make a huge difference in terms of the actual medical condition – but as we know, the diagnosis is not the same as the health condition! And it’s health status on which CBT really has an impact in chronic health conditions.

Although it’s similar to the way CBT is applied in mental health situations in terms of looking at thoughts, beliefs, rules, attitudes, emotions and behaviours – it’s much more about the helpfulness of these things than the ‘accuracy’ of them. In mental health, often the thoughts are inaccurate – ‘other people think I’m bad’ or ‘I must keep my hands clean or else it will be a disaster’ or ‘I’m totally inadequate and nothing I do is good enough’.

In chronic health it may be more like ‘I can’t trust medicine to fix me’, or ‘If I keep bending, my pain will get worse’, or ‘I should be able to cope with this’. Some of these thoughts are accurate, some are inaccurate – and some may be accurate but are unhelpful.

So, as therapists, we are concerned with helping people become aware of usually hidden thoughts and beliefs. We then help the person identify whether these beliefs help them achieve their life goals (or valued/important activities), then alter them or work to establish ‘exceptions’ that may help them rather than hinder them.

At the same time, we’re working with the person to achieve personally relevant goals – things like achieving refreshing sleep, being able to return to paid employment, communicating well with their families, having invigorating leisure time. These activities require planning, monitoring achievement, altering behaviours and recruiting support in order to achieve them. And yes, these are all legitimate areas for input by an interdisciplinary health care team.

The process for me is to start with really good assessment across the domains that are relevant for the health condition in question. In pain management, I’m interested in attitudes, behaviours, compensation, diagnostic beliefs, emotions, family and friend interactions, and work – amongst a lot of other things. From this I want to add in – what does this person want to be able to do? What does the person referring him or her want them to do (why did they refer this person?).

Then I want to work with the person to help them achieve their goals – this means developing some ‘working’ explanations for how they’ve arrived at having the problems they are experiencing. Because I use a biopsychosocial model, I try to put together the information from all three domains – biophysical, psychological and social. This process can take quite a while, and doesn’t need to be complete – and for me, has to be shared with the person.

Most of the time the person is quite clear about how well this explanation ‘fits’ for them – and it’s not so unfamiliar for many of us who work as therapists. We usually give an explanation for the treatment we are giving – the main difference is that we work collaboratively with the person and recognise that we actually don’t know whether what we are suggesting is the ‘correct’ answer. This is because in most chronic health management situations, it’s not a simple 1+1 – it’s more a case of multiple factors interacting in a bunch of ways!

Applying CBT isn’t confined to cognitive theories, or behavioural theories, it’s much more about values – and readiness to act, based on importance and confidence – as well as allowing people the opportunity to choose.

How does this differ from normal therapy? Not a lot really – it’s simply expanding our treatment model to include factors that we know influence whether a person will or won’t change their behaviour. And this should apply to any health professional – physiotherapists need to know that people will carry on with their exercises, occupational therapists need to know what stops someone incorporating working to quota, social workers need to know how to help people approach anxiety-provoking activities, and nurses need to help people complete daily recordings!

But – more tomorrow!