Two strikes and you’re out – referrals and readiness

I’m in a bit of a dilemma. As you know, health resources are scarce and it’s not easy to get an appointment for treatment of a chronic condition. There’s something to be said for making sure that our precious health care time isn’t wasted by people who would rather not be there.
On the other hand, there is also something to be said for people being in the right headspace, or in more technical terms, the right stage of readiness to engage in therapy. If the person is referred for treatment before they’re ready, it’s going to be difficult for them to engage – and they may very well do the resistance thing that we see so often ‘yes, but’, ‘OK but’ or not actually do what we’ve suggested they do to help manage their condition.

The discussion that has raised this in my mind happened on Monday. (more…)

Goal setting: A critical skill for change

Pain management is many things to many people, but most of us would agree that if life hasn’t changed in some way after pain management, then it hasn’t really been effective.  For change to actually happen and be maintained, Prochaska and DiClemente and others (eg Miller, Rollnick and colleagues) identify that people must believe the change to be important, and that they have the ability to make it happen successfully.

I’ve posted earlier on self regulation (eg this reading, and this post), making the point that it is made up of several components, one of which is goal setting.

When I went to Google to search the words ‘goal setting’, 13,200,000 hits came up in 0.16 seconds, so goal setting seems to be rather popular – and yet it’s often the most difficult session to facilitate in the three week pain management programme I work in, and some of the ‘goals’ I’ve seen written for patients just don’t look anything like the kind of goals that can actually be measured! So perhaps goal setting is both popular but not easily carried out in ‘real life’.

So, how do we set goals?
It sounds easy if you’ve learned to set goals early in life, but for so many of the people I see it’s not a familiar activity. The research literature in psychology abounds with various models and influences on goal setting and achievement, which doesn’t really help a busy practitioner who may well be drawing on knowledge from first year professional training! And unfortunately, the information readily available online is often of variable quality.

I’m going to start with some random thoughts, mainly based on conclusions drawn from a motivational approach – tomorrow I’ll fill in with some literature!

Firstly, goals need to be relevant to the person. That means that the person believes that the goal is important. Importance is predicated upon things that the person values (see the New Zealand School Curriculum definition here)- these are usually abstract beliefs that, through action, become evident. The same action can represent many values (eg daily exercise can represent ‘time out’, ‘commitment to my wellbeing’, ‘a way to keep my partner/husband/dog happy’). And similarly, values can be fulfilled or operationalised in many different ways (eg ‘caring for my family’ can be achieved by ‘being in a high paid job’, ‘being home when they get home after school’, ‘always going to sports activities with the kids’).

Sometimes, the values appear to conflict with each other – it’s quite common for someone (perhaps yourself?) to value ‘being healthy’ while at the same time valuing ‘relaxing’ – how those values are played out in the real world may mean the person eating healthily in one part of the day, then drinking alcohol as a primary way to relax! I’ve seen this in people who say on the one hand that they’d like to return to work, but on the other, they don’t think they can – because they can’t continue working in the way that they’re used to. There is a conflict between two different values: the values that constitute ‘being a good worker’ (which is operationalised as ‘always doing a job at 120%’) and ‘being able to cope’ (which is operationalised as ‘never allowing my pain to fluctuate’).

The second is that goals need to be achievable.
That is, the person needs to feel confident enough that they can actually succeed in making the goal happen. When pain becomes chronic, confidence to achieve goals can often be eroded, especially if pain is feared or avoided. Successive failures to achieve goals only serve to confirm that taking a risk by setting a goal should be avoided. And this seems to be much more the case if the goal is particularly important – and of course, if it’s not important at all, it just won’t happen!

It almost goes without saying that goals need to be specific and measurable
– exactly what is it that the person has to do, and how will they know they’ve achieved. This is much more difficult if the area of goal development is complex, or requires sub-goals to be achieved in order to attain a longer-term goal.

Tomorrow: some readings on goal and goal-setting, and over this week – tools to use to help people set and maintain goal-directed behaviour.

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When you need to change tack…

There are some times when things just don’t go the way you plan…Therapists don’t very often publicise when things don’t work out, but I think we can learn a lot from these situations – and the reflection process models one of the ways that we can help patients learn from every situation too. As one saying goes ‘it is not a failure, it’s a learning experience’!

So, with this particular client, I found myself in a ‘yes, but’ situation…this situation occurs when I’m asking the person to take action before they’re ready.
This man is a Very Busy Man – a ‘type A’ if you like. He’s a professional, in a senior position in a medium-sized organisation, and very, very busy. He works 10 hour days, rarely takes breaks (even lunch), and takes work home. He has had an exemplary work record, very few ‘sick’ days – but when he has abdominal pain, he can end up in Emergency Department. His admissions have increased in frequency over the past 12 months, and he is now asking for ‘something’ to help so he doesn’t have to be admitted to hospital, but can carry on at home.

As I assessed him, I thought the most important areas of concern were these:

  • when he experienced discomfort he tended to not notice it until it became overwhelming
  • when he became aware of his pain, he became very fearful and immediately used pain medication or sought medical care
  • he rarely communicated his pain concerns to anyone, and had been careful not to tell anyone at work
  • he had few friends and his relationships at work were somewhat distant
  • he and his wife were very worried about his health and were very keen to have his pain completely abolished
  • he was very capable of focusing and becoming completely immersed in his work
  • he had a limited range of relaxation or leisure activities

I started with offering him the menu of options, and mentioned that I had observed from the assessment he had completed with our service that he was finding it difficult to relax, and I wondered whether he would like to see how relaxation might help him.

His response?

‘Yes, but…’

And what came next was a long list of reasons why he couldn’t relax – his job was too busy, he enjoyed the ‘buzz’ of pushing himself to achieve, he was aiming for promotion, he was ‘carrying the load’ for other people at work….

I tried another tack, and reflected to him that he must find the thought of relaxing quite strange and perhaps that it felt unnecessary and a ‘time-waster’ – to which he said ‘yes’ and that what he thought he needed was to have his pain ‘properly managed’ and that ‘doctors must be able to find the cause of my pain and fix it’.

hmmmm… time for a moment of quiet reflection!

Once again I used reflective listening to let him know that I ‘heard’ what he was saying, and suggested that perhaps it might be a good idea to see if we could have a joint consultation with one of our doctors to review the medical situation, to ensure that he had the best advice available on whether a ‘fix’ was available. If there was a medical area for follow-up, that’s great, if not – the door was always open for him to come back.

Using the review process, I spent a bit of time thinking about what had happened – why had CBT and my suggestions fallen flat? What could I do differently?

I use a semi-standard set of questions (well, some of them are the same every time!):

  1. What did I do well? I think I went well with rolling with his resistance – using listening skills to demonstrate empathy and respect.
  2. What was not so good about that session? I misjudged his readiness to begin making changes and to see his pain as ongoing.
  3. What was particularly frustrating? For me it was that he wasn’t ready to move on from finding a ‘cure’ or ‘fix’.
  4. What was the most satisfying aspect about this session? That I recognised this and rolled with it instead of getting into a ‘yes, but’ situation.
  5. What skills did I use? Listening skills and a range of ‘motivational’ approaches including the menu and listening skills.
  6. What skills could I have used? Asking him what he wanted or thought was his ‘next best step’. Perhaps asked him what went through his mind when he experienced his pain at work, or started to feel pain and ‘knew’ he needed to go into hospital, or even asking him about what was important about maintaining his pace at work and establish the discrepancy between this value and what happened when he went into hospital.
  7. If I could wave a magic wand, what would I change about the situation? Spend more time listening to what he wanted before starting on a menu that assumed he was ready to make any changes at all.
  8. What extra resources could I draw on? Going through his medical file and working with his medical doctor to establish his readiness and what the options were – helping him come to a point of ‘creative helplessness’
  9. What would I do differently next time? Listen first, talk less, assume nothing.

Now I don’t use all these questions all the time, and some of them I don’t use often at all (particularly the magic wand one!! that would be too tempting…)
Is CBT the right approach? Yes – but with a tweak or two to make sure this person is at the right point of readiness before starting to introduce change.

I hope this post has helped you see some of my thinking style and that we never stop learning! By drawing on a range of different therapeutic styles that hold to a similar value base, we are able to respond with flexibility to people at different points in the change cycle.

If you want to continue reading about how I apply CBT and other therapies in chronic pain management – don’t forget you can subscribe using the RSS feed above (just click!), bookmark this blog, and comment!