physiotherapist

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).

(more…)

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. (more…)

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!

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.

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.