Teams, roles, and contributions

I’m quite keen to generate some more discussion about how individual professions can contribute within Interdisciplinary/Interprofessional Team without being defensive of their contribution, nor allowing other disciplines to encroach on their specialist skills.
I really struggle with the whole concept of “role definition” because so often I see “the OT role is…” without considering that there are a number of core areas many health professionals in pain management use such as goal setting, relaxation, pain “education”, activity pacing/management, relaxation, biofeedback, cognitive behavioural therapy.

Some examples: Once I heard an occupational therapist say that only occupational therapists should “set functional goals”. Yet if goal-setting is client-centred, I can see how physiotherapists, nurses, social workers, psychologists and doctors can ALL work with a person to “set functional goals”.

I also heard an occupational therapist suggest that “only” occupational therapists should go into the home, or workplace. Yet I’ve had some fabulous physiotherapists and psychologists go into both these places and do fantastic work.

The current debate is whether occupational therapists or physiotherapists should do mirror therapy or laterality training.

Sadly I also heard of a doctor who told the interdisciplinary team that he thought it was fine to advise a person to begin a walking programme – without consulting a physiotherapist! Oh no! How dare he! Actually, isn’t this what many nonmedical clinicians have been wanting our doctors to do? And if a physiotherapist begins talking about function in the real world, isn’t this what occupational therapists have been saying physiotherapy doesn’t do but should? Seems to me we don’t recognise our own cognitive dissonance even when it’s sitting right in front of us.

To be quite honest – I don’t care WHO does what! As long as a clinician is competent, the client has had a hand in establishing priorities, and there aren’t two clinicians doing exactly the same work, to me it does not matter.
BUT I’d love to find out some other points of view, and poke holes in my assumptions – so, go to it ladies and gentlemen!

Someone asked me “so what are the skills people should have to work in chronic pain management?”

1. I’m thinking about this right now – firstly, people who “get” pain. So well-educated, knowledgeable people who have a really good grasp on neurobiology and psychology of pain. I don’t really care about the professional background, but I’d like someone who can reassure patients/clients that their pain (a) has a name (b) doesn’t mean its harmful (c) can be managed. I would help if one person in the team can prescribe rationally.
2. Someone should address movement and pain – don’t care if it’s an occupational therapist, physiotherapist, exercise physiologist or whatever. Best if this person can grade movement from simple/low intensity to higher and definitely functional intensity. And critically, that person needs to know the relevance of any exercise on what the client/patient does in daily life.
3. Someone else needs to talk about the meaning of pain on the sense of self, and help the person understand that doing things differently doesn’t mean losing your self concept.
4. It would be good to have someone who understands behaviour, and interactions between behaviour, emotions and cognitions.
5. Absolutely, someone in the team needs to help the person identify what they WANT to, or NEED to do to feel complete, then help the person work out ways to do that.
6. And I think it’s vital someone can interpret psychometrics, and knows enough about outcome measurement to produce regular reports on how participants in pain management are doing once they leave the service.

And all the other things like using biofeedback, diet, relaxation, communication, health literacy, would need to be incorporated by those will skills in these areas.

I think teams need someone who will bat for them in management, someone who really cares about the team and how it functions, and will wave the flag in terms of retaining an interdisciplinary self management focus, ensuring the team remains client-focused and team-focused, rather than discipline-focused.

Teams need to negotiate their contributions (note I say contributions not “roles” – contributions are offered, roles are defined and possessive). Team members need to renegotiate what they can offer when new team members join the team, or when a team member develops a new skill. Defining one “role” means, implicitly, that other roles are also “defined”. Sometimes this happens without negotiation. And if role definitions are not regularly reviewed, innovation and responsiveness drops, positions get reified – and we end up with a cookbook approach to pain management that means the personal relationship between the person who has pain and his or her clinicians is valued less highly than the professional title of the clinician. I don’t see this as client-centredness.

One argument for defining roles is to avoid duplicating skills. It’s intended to ensure “the right clinician with the right skills sees the right patient at the right time”. I think this ignores the common skills all clinicians working in chronic pain management need. It ignores individual team member development. It means clinicians who are not “meant” to do the tasks nominated within another role’s definition can’t develop their skills to support one another within the team. It creates barriers and obstacles to developing a common language, using a common model (cognitive behavioural approach, in the case of chronic pain management), developing common goals. It can lead to multidisciplinary practice instead of interdisciplinary/interprofessional teamwork.

It can, unintentionally, create over-servicing because instead of selecting clinicians to work together on the basis of what the client/patient needs, professional demarcation lines are drawn and THREE clinicians need to work with the client/patient instead of two. Maybe even more because if the person needs to develop communication skills at work – maybe the occupational therapist “should” work on this; if the person needs to develop effective communication at home – maybe the social worker “should” be involved; maybe it “should” be the psychologist because it’s about the person’s core schema. See how complex this can become? It’s even more difficult if we look at activity management. Should the occupational therapist be involved because it’s about occupation? Or the psychologist because it’s about contingencies and core schema? Or the physiotherapist because it’s about building exercise tolerance? Or the social worker because it’s about negotiating boundaries with other people?

Teamwork – more than a group of clinicians who happen to work with the same patient.

 
Sandra G Leggat (2007). Effective healthcare teams require effective team members:
defining teamwork competencies BMC Health Services Research, 7 (17), 1-10 : 10.1186/1472-6963-7-17

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If you’re new to pain management

This is just a brief foray into thinking about what people new to pain management might need to know in the first few months.  I’m definitely not being academic about this, and I don’t have any references – it’s my reflections on seeing people starting in the field looking a bit like a possum in the headlights!  (For non-kiwi’s, the possum is high on cuteness, and more than high on destructiveness – and one of the best ways to catch a possum is to go spotlighting!)  (Photograph by PJWood, apologies for not crediting this before, this image is common on the internet).

Why do they want me to see a psychologist – I’m not nuts, I just have pain!

Explaining to someone that seeing a psychologist about chronic pain might be helpful can be a bit like this:

Yup, brick wall – hard object!

I can see it from the person’s point of view – it’s taken a long time (usually) for medical and other people to recognise that this pain isn’t simply going away, and isn’t about the person being ‘pathetic-why-don’t-you-just-pull-yourself-together’, so when someone suggests that psychology might be helpful it’s like saying ‘You’re nuts, you’re just losing it’ – or worse, ‘you’re a hypochondriac’.

I thought it might be helpful to review some ways to introduce the idea of seeing a psychologist (or other allied health person), or using a CBT perspective in pain management.

Working with goals

I mentioned in my post yesterday that it’s not easy to help people work out goals.  Most people have a fairly general idea of how they’d like their life to be, despite pain, but have lost sight of the possibility of how life might be in the future. I spoke about this with a person this morning who told me that he has lost confidence that life can be anything different, so when he was asked ‘what do you want from pain management’, he was floored!  He told me that he has lived ‘from day to day’ for so long that he had lost sight of considering where he was going in his life. I don’t think this is uncommon for people living with long-term pain, before they start accepting pain as chronic and start ‘living’ with their pain.

So the first step may be to use a menu approach as I suggested yesterday, but somehow this needs to lead in to longer-term ‘life change’ goals, so the new knowledge can be integrated and retained.  My vision for people learning to live with pain is that they move from thinking of themselves as ‘patients’ and move to thinking of themselves as ‘people’ – and more importantly, that they are people who are doing things. That way their pain condition becomes no more important a part of them than their height, ability to do maths, or interpersonal skill: just part of who they are.

We’ve discussed the menu approach, which helps people to look at things they’re interested in.  Then quite often we help the person develop the pain management skills are linked to the clinical hypotheses we, as clinicians, developed about the factors that we have assessed as influencing their pain presentation.  These are may be things like activity management, relaxation training to reduce physiological arousal, communication skills and so on…

Then the part that I think is vitally important, but not always recognised: change management in ‘real life’.  Some people call this ‘goal setting’!

The ‘wish list’ (I promise I’ll feature this tomorrow!) asks people to identify general areas they’d like to see change in their lives.  This goal-planning worksheet is one way to help people develop specific ‘next steps’ to take, and ways to identify and measure the actions and resources they need to take to make it happen.

Click on it, and you’ll be able to see that in the centre is the ‘goals area’. I’ve described this as ‘I want to…’ with lots of space to draw or write exactly what the person wants. If they can’t be very specific, that’s fine because details are refined as part of this worksheet process.

Starting at the top, working clockwise, are a series of headings that the person can complete that will help shape up the way to achieve the ‘I want to’ part. Going in order is important (from top, clockwise), because each section builds on the others.

Step one and probably most helpful for retaining motivation is ‘Why is this important to me?’. We know that internal motivation is drawn from values, or reasons that something is important. By helping the person think through why they want this change, we help them generate their own reasons for change, rather than reasons we might generate.

Step two is about time frame: often this depends on the level of confidence the person has for acheiving their goal.  The time frame also may determine the steps the person may take, and reflect other people’s actions or proceses (eg case manager). It may be helpful to revisit the time frame once other areas are completed and adjust, but it’s useful to work out what the person believes is possible first.

Step three is about where the goal will be achieved – for example, at home, at work, in a clinic… This may help determine the strategies that can be employed.  Some activities can be used in one setting, but not another, while it may be important to help the person see that they can achieve in one setting before generalising to another (eg using relaxation at home to enable them to complete vacuuming, before developing the skill to self-regulate at work, where it can be much more difficult).

Step four asks about general resources the person may need. This can be revisited also, but is often the real action phase of goal setting.  It’s OK to not know all the resources required – this may, in fact, be one of the sub-tasks required to achieve a goal.  So it’s fine to put down ‘I don’t know what resources are available – I’ll need to identify these as my ‘next best step” – which is one of the other steps in this process.

Step five identifies the ‘people’ resources the person has to help them achieve their goal. This can range from speaking to their partner, family or friends, right through to asking for a referral to see a specialist career counsellor.  If the person is receiving compensation, and has a case manager, then the case manager must be one of the ‘people’ identified in this step.  You, as health provider, should also be listed.

Step six is about what the person can do to recruit help from people – because it is all about self management and self responsibility.  What does this person need to do to get the help they want? Do they need to write letters? Meet with someone? Leave notes? Arrange regular phone calls?

Step seven identifies ‘what are my next best steps?’. This can be about finding out resources, contacting people who can support them, maybe identifying where the goal can be carried out, or even refining the time frame.

Finally, (and next to ‘why’, the most important part of this process) is ‘how will I know I’ve achieved my goal’. This is often the most challenging part of this whole process, because it provides the person with a specific way to measure achievement. This may require additional input from you as health care provider.

It’s not very easy for someone to think about how they will know whether they have achieved a goal – quite often the person hasn’t thought about the goal in more than general or vague terms.

For example, a goal may be ‘to sleep better’.  This isn’t precise enough for anyone to decide whether the goal has been achieved or not.  Remember that subjective feelings ‘sleeping better’ are often determined by proximal experiences (a bad night’s sleep or two close to the day the person is asked about their sleep will likely influence them to say it is no better), and by demand characteristics of the person asking (a treating clinician will obtain a different answer than if the person’s partner asks), as well as a number of other response biases.

It’s far more effective to ask the person ‘how will you (know) measure that your sleep is better?  Is it that you sleep all the way through the night, every night of the week?  That you wake up feeling like you’ve had a good sleep, five days out of seven?  That you no longer use any sleeping medication to help you get off to sleep?’

These latter measures help identify the different ways that ‘success’ can be achieved, and as a result both reduce the chance for measurement biases as well as determine just what the ‘end point’ will be (at what point will the person be personally satisfied with their progress?).  It’s much more client-centred, as well as more easily recorded and reproduced.

Have a go at using this worksheet for a person goal for yourself.  What would you like to see different in your life?  Then work out how you’ll achieve it using this step-by-step process.  Let me know how you go!

Group facilitation

I love working in groups! I love the diversity, and the way that learning occurs, and the challenges of energising and focusing groups. For me groupwork is one of the most demanding and yet rewarding aspects of my work.

There are many many sites on the internet that have a range of activities for groups – a good number of them are free. What they don’t seem to do is help with how to integrate the activities so they not only energise and warm a group up, but also provide a venue for serious learning.

I’m going to describe two activities that I’ve enjoyed using with groups who are developing pain management skills.

The first is used within the first week (often the second or third day), and the second is best used towards the end of a programme. The purpose of each activity is to allow the group to focus on the activity while forgetting about their pain, so that they can develop awareness of what their ‘high risk’ behaviours are with regard to learning new activities, integrating pain management strategies, and in a sense, how they live their life. I subscribe to the idea that ‘how you do anything is how you do everything’ – so how people participate in these activities is probably how they will respond to situations in the real world.

There are some common tasks as facilitator for both activities, and I’ll describe these as a preamble to the specific activities.

The purpose: to enable the group members to respond naturally to a ‘demand’ situation, to assist them to reflect on the way they approach activities (‘life’)

My role: facilitate, set task parameters, enforce ‘rules’ or boundaries, assist the group to reflect and generate their own learning, ensure the equipment and environment is established for mental and physical health

Pre-activity: set up environment, ensure the instructions are printed and clear, ensure all equipment is available, have stop-watch or timer set up, and that adequate time for both briefing and debriefing has been allowed for.

Post-activity: ensure all participants have had time to reflect, all have been facilitated to hear what you as facilitator think is important, and that group process has been allowed to flow, the participants have written down ‘key learnings’ from the session, and you have been able to clean up.

Group size: 4 – 9 participants

Activity one – ‘Crossing croc-infested waters’

Materials: 5 A4 sheets of paper, tape to mark floor

Preparation: tape a ‘river’ across the floor – the ‘river’ should be at least 3 m wide, and about the same deep (or as wide as your room!)

Instructions: Tell the group that they are required to cross the river which is full of crocodiles. They have five stepping planks that they can use to cross the river with, but because they’re made of wood and float, once they are placed down in the water, they must be held down with a foot at all times or they will be swept away! The group must rely on each other, and work out how to get all members of the group across the river safely using only the five pieces of paper. They must not allow anyone to ‘die’, neither can any part of their body touch the ‘river’ or it will be ‘eaten’. They have 10 minutes to complete this activity.

Facilitator role: It is very important to enforce that the pieces of paper must be held down at all times. This is often forgotten unless the group have rehearsed the activity on ‘dry land’, and learning to rely on each other and work together as a team, watching out for each other and coordinating their movements. The facilitator must also urge speed and maintain a watch on time, particularly as the activity nears the end. To make the task more difficult, the time can be made shorter, or a piece of paper can be removed. It’s also important that no-one puts their foot in the ‘water’ (or they may not put that foot down again – it’s been bitten off!)

At the end, the facilitator must conduct the debrief – see attached pdf doc.

Activity two – Radioactive Rice

Materials: two cups, one filled with uncooked rice, various items from around the room including sheets of paper, tape, spoon, icecream sticks, pottles, string, bluetac, chalk, instruction sheet

Preparation: draw a circle with chalk on the table (circle is usually about 1m radius). Place one cup filled with rice in the centre of the circle. Collect other assorted items around the table.

Instructions: Tell the group that this is a heavily disguised cup of radioactive rice that will blow up in 30 minutes, creating a huge crater of radioactivity and killing all within a 2km radius of the area. Inside the chalk circle is an invisible containment field shaped like a cylinder, going from ceiling through the table to ground level. This is currently holding the radioactivity inside it. The rules are:

• No body parts are allowed to enter the containment area
• No-one is allowed to commit suicide and sacrifice themselves to remove the rice
• No items that are outside the room are allowed to be used
• Anyone who breaks the rule is ruled out and cannot be physically involved from then on (not the word physically involved! it’s OK to talk…!)
• As much or as little rice can be transferred at any one time
• The group has 30 minutes to transfer the rice from one cup to the other, then to remove the second cup to the ‘safety zone’ before the whole area will blow up

I usually allow 5 minutes question time then I will stop answering any questions and allow the group to get to work.

After 30 minutes, time is up and it’s debriefing time.

Facilitator role: It’s very important to stick to the rules at all times, maintain a very close watch on the participants and firmly tell them they are out if they break the rules. Every 5 minutes for the first 15, count time, thereafter every one minute, and in the last two minutes, every several seconds. Ensure people who are ‘out’ don’t get physically involved – but remember they are allowed to remain in verbal participation! Managing the debrief is essential.

Debriefing: for both of these activities, debriefing is essential!

In each case, these activities represent ‘life’ – and how people go about managing their participation is very similar to how they will participate in ‘real life’. So, some people will work together with others, think and plan, and manage both themselves and their pain using a wide range of skills. Others will completely forget to manage their pain, jump right in and break the rules very quickly.

This document (activity-review-jan-2008.doc) can be used for individual review.

As well, the group can be facilitated to provide review to each other – this is a very powerful way for people to develop knowledge of each other, and to learn to give and receive feedback (positive and negative). I usually start with asking the group ‘what did you do well?’, and ‘what would you do differently?’, then I ask the group to contribute both types of feedback, and finally, ask the person ‘what will you take away from this experience today?’.

Often it’s helpful to reflect on ‘what happened when I was counting the time down?’ – it’s adding pressure, and mimics a working situation.

Asking ‘and what happened to your pain during the task?’ reminds people of the usefulness of distraction, and that it can be a trap because pain becomes more problematic afterwards. Most people forget to use pain management strategies, so it can be a potent learning tool to remind them that they need to integrate pain management strategies even during activities like this that are involving and distracting. I also like to remind people that they always had a choice – they could have told me that this activity was silly, not real, and chosen not to participate! But they may have missed an opportunity to learn something – which is pretty much what life is like!

Reflecting on ‘What did it feel like when you were told you were out?’ is a powerful experience – many people say that they felt gutted, stunned, angry, and some argue against the rule. It’s useful to draw the parallel with the experience of suddenly having pain, when all the physical things they used to do were restricted (but equally powerful to emphasise that people were still able to contribute verbally – many people don’t remember this, and it can be both humbling and empowering for people to realise that they self-limited their involvement by not clarifying their position).

At the completion it’s important that participants write down their take-home messages – it’s impressive how many are aware even at the beginning of a programme, exactly what their particular pain management ‘trip-ups’ will be, but equally impressive to notice that even by the end of the programme, they will still fail to integrate their skills.

I hope you enjoyed this introduction to two activities I’ve used with people to help them learn experientially.

Supervision

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)
1	To provide a regular space for the supervisees to reflect upon the content and process of their work	Educational
2	To develop understanding and skills within the work	Educational
3	To receive information and another perspective concerning one’s work	Educational/Supportive
4	To receive both content and process feedback	Educational/Supportive
5	To be validated and supported both as a person and as a worker	Supportive
6	To ensure that as a person and as a worker one is not left to carry unnecessarily difficulties, problems and projections alone	Supportive
7	To have space to explore and express personal distress, restimulation, transference or counter-transference that may be brought up by the work	Administrative
8	To plan and utilize their personal and professional resources better	Administrative
9	To be pro-active rather than re-active	Administrative
10	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.

A couple of references for you:
This one is from Mark Smith who is part of infed. This site has a good number of thought-provoking articles on life-long education. Well worth a look.

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.

Pain management can’t be cloned

I’ve had occasion over the past few weeks to think about service delivery and teamwork and how to provide really good pain management programmes in a group context.

A problem with any interdisciplinary team is that the members of the team may change as staff leave, or are unwell, or even have annual leave(yes! we like to take a break too!). At the same time, programmes for people with pain need to be provided consistently and often enough to break even financially.

The economic viability of interdisciplinary group pain management has been established (see these papers by Gatchel & Okifuji (2006), Goossens, Rutten-Van Molken, Kole-Snijders, Vlaeyen, Van Breukelen, & Leidl (1998), Turk & Burwinkle (2005) for discussion), and we know the effectiveness of this approach on individuals from too many studies to list here. Often however these outcomes can be overlooked in the face of the need to resource a programme with professional staff members, facilities, administration, outcome measurement, and ongoing review and development. So managers sometimes think of ways to reduce the cost in the most expensive resource – the staff members and the time spent on reviewing and developing programme content.

The argument seems to be one of two:

1. That once a programme has been developed, there is little need to review it, and a ‘cloning’ approach can be used (similar to a franchise strategy!)
2. That once the programme has been developed, the professional involved in the programme can simply ‘teach’ the contents – and perhaps ‘any’ professional can do this…

Let’s take a look at the first argument – that programmes can remain essentially the same once they’ve been set up. I’d argue that because pain management is continuing to evolve and develop, it becomes foolhardy not to include the findings and ‘technology’ based on new research findings. For example, in the last 5 years the literature on the pain-related anxiety and avoidance model (Vlaeyen & Linton (2006) has rapidly established the place of behaviour change and exposure-based therapy for people who are fearful of movement or pain. Programmes ignore pain-related anxiety and activity avoidance at their peril. Review and update are necessary in all areas of health care – no less so in pain management.

The second reason, that therapists can be slotted in and out of programmes as required – provided that they can ‘teach’ the content, suggests that the technical needs of cognitive behavioural therapy have been misunderstood. CBT is not simply providing information to people – it is a process of reconceptualising concepts, developing and rehearsing new skills, and reviewing situations to problem-solve and develop strategies so that the next encounter can be successfully managed.

As I’ve written about before, interdisciplinary teams need certain things to be effective – these include

• a common model that all members of the team are well-versed in
• technical skills in providing cognitive behavioural therapy
• group facilitation skills
• knowledge and trust in each other as professionals
• ability to work across professional boundaries as necessary so as to reinforce the common model

To achieve this state, I think these things are essential

• really good induction
• time together as a team
• agreement to adhere to the programme process
• systems and structures to support decision-making
• opportunity to observe the team members and programme

It is simplistic to think that the best way to ensure an economically viable programme is to reduce costs in the areas in which the ‘technology’ resides – the therapists and their skill, and ongoing review and development of the programme.  Not to mention time and processes to develop teamwork.   Although it’s expensive up-front, this time and effort is recouped in the quality of the programme and the outcomes it achieves.

On a slight tangent – can a successful programme from one country be transplanted holus-bolus into another country across the other side of the globe?

Some things concern me about this – the ‘franchise’ approach which prizes adherence to a manualised approach and can prevent ongoing development; the belief that professionals in one country have the same background and training as in another country (especially with respect to occupational therapy training!); the thought that patients can be cloned and ‘one size fits all’; and finally the suggestion that the active ingredients in the programme will ‘fit’ with the social, economic and political climate in another country.  I don’t know that this is achievable in chronic pain management…and wait to see with a good deal of interest whether it can happen here in New Zealand.

Let me know what you think about this post – agree? disagree? want to point out arguments for and against? Bring those comments on!!

Gatchel, R. J., & Okifuji, A. (2006). Evidence-based scientific data documenting the treatment and cost-effectiveness of comprehensive pain programs for chronic nonmalignant pain.[see comment]. Journal of Pain, 7(11), 779-793.

Goossens, M. E., Rutten-Van Molken, M. P., Kole-Snijders, A. M., Vlaeyen, J. W., Van Breukelen, G., & Leidl, R. (1998). Health economic assessment of behavioural rehabilitation in chronic low back pain: a randomised clinical trial. Health Economics., 7(1), 39-51.

Turk, D. C., & Burwinkle, T. M. (2005). Clinical Outcomes, Cost-Effectiveness, and the Role of Psychology in Treatments for Chronic Pain Sufferers. Professional Psychology: Research and Practice, 36(6), 602-610.

 

Vlaeyen, J. W., & Linton, S. J. (2006). Are we “fear-avoidant?” Pain Vol 124(3) Oct 2006, 240-241.

 

A personal bias

Now some readers have been wondering what my background is…Sometimes I feel like being rather provocative and asking why – while other times, like now, I feel like ‘fessing up.

Here is a clue: in pain management, to me the most important thing is to see people doing things differently.

That’s right, although I’m a strong believer in working with thoughts and beliefs and values and so on – if it doesn’t mean something observable changes, it didn’t work. My aim with pain management is to help people do what they want to do, to be in control so they can achieve their potential, not just ‘feel better’. Likewise with teaching – if I haven’t stimulated you to do something differently, then I’ve failed.

My reason? Well in pain management, because pain is a quale, that is, it has sensory and emotional qualities that we can’t directly share with each other, we cannot ever know how much pain another person is feeling. The only clues we have that pain is present (or not) is what the person does about it. That is, behaviours or actions. Even when the experience is an emotion, you and I can’t share the emotion except through the medium of language or action.

So we infer that pain is present on the basis of behaviours (including speech). This is one reason that, as clinicians, we can never truly say whether someone is ‘malingering’ or ‘faking’ (that’s more likely the job of a private investigator!) – and if behaviours are the only aspect of pain that we can observe, we also need to acknowledge that behaviours are subject to all the influences of any behaviour, such as contingencies and social learning as well as cognitive aspects such as attitudes, beliefs and so on.

As a result, we can do a whole heap of work with someone’s thinking, but unless they do something differently, nothing has really changed for them. If they feel more positive, hopefully we could count smiles; if they are less distressed, hopefully they will go to the Emergency Department less; maybe even return to work! We also know that if people do more, feel better about themselves, and they’re able to do more!

This isn’t new stuff – this is pretty fundamental to the operant conditioning model of pain introduced by Wilbert Fordyce in the early 1980’s onwards. By conceptualising pain behaviour as the subject of treatment, Fordyce introduced the idea of living despite pain. By noticing that reports of pain intensity vary depending on distress, depression, reinforcement from over-supportive others and so on, psychologists recognised that if pain behaviours reduce, often reports of pain intensity reduce. And more importantly, people began to live lives again. Now that’s what I’m about!

For more from the man himself, here are a couple of the original articles – plus a couple of others that are important to explain the biopsychosocial model.

Did the clue help? Do you know what ‘flavour’ health professional I started off as? Do you know what flavour health professional I am now? Does it really matter?

Fordyce, W. E. (1984). Behavioural science and chronic pain. Postgraduate Medical Journal, 60(710), 865-868.

Fordyce, W. E., Roberts, A. H., & Sternbach, R. A. (1985). The behavioral management of chronic pain: a response to critics. Pain, 22(2), 113-125.

Fordyce, W. E., Shelton, J. L., & Dundore, D. E. (1982). The modification of avoidance learning pain behaviors (Journal of Behavioral Medicine. 5(4):405-14, 1982 Dec.).

Gatchel, R. J., Peng, Y. B., Peters, M. L., Fuchs, P. N., & Turk, D. C. (2007). The biopsychosocial approach to chronic pain: scientific advances and future directions. Psychological Bulletin, 133(4), 581-624.

Turk, D. C., & Monarch, E. S. (2002). Biopsychosocial perspective on chronic pain. In D. C. Turk & R. J. Gatchel (Eds.), Psychological approaches to pain management (2 ed., pp. 3 – 29). New York: The Guilford Press.

Oh, here are some other on-line bits and pieces on the biopsychosocial model. Firstly, a review of a video by Bob Gatchel on Pain Management using the Biopsychosocial Model…

For those who don’t think a full-on postgraduate course is possible, this on-line CME course may be helpful:
UCLA CME course

And don’t forget the University of Otago, Christchurch, papers in Pain and Pain Management – see the link to your right…

Chronic Pain’s Favourite Tools

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.