The complexities of interdisciplinary teams
Pain management, especially chronic pain management, is characterised by using an interdisciplinary approach rather than a multidisciplinary one. Distinguishing between the two can be a case of splitting hairs at times, but the fundamental difference is that in multidisciplinary teams, treatment is carried out by different team members who may work with the patient concurrently, but not necessarily using the same underlying model or framework for treatment. In an interdisciplinary team, treatment is carried out by different team members using a common model to address common goals – working collaboratively and in close communication with each other.

Interdisciplinary teams take time to develop. The members of the team learn more about each other’s professional roles the longer they work together. They become familiar with, and trust each other to support the common messages such as ‘don’t use pain as your guide’, or ‘do no less on a bad day, do no more on a good day’. Interdisciplinary teams rely on each other to help the person with pain move forward towards the life they want to live.  To become effective, interdisciplinary team members need to learn to trust each others practice, to have confidence in their own practice, and to develop a common language and approach to clinical situations they encounter.

The problem with these teams is that much of the ‘work’ of a team occurs during meetings, and meetings of groups of health professionals look costly. Five or more therapists sitting together for a couple of hours seems to be an inordinate waste of productivity when you think of the number of patients they could be seeing during that time! Not only that, but developing effective team processes including good induction and dispute resolution also takes time. And it’s invisible input with little visible output. No wonder managers think teams like this could surely be done differently.

The research on effectiveness of interdisciplinary pain management continues to support this model, despite erosion of it in some countries (notably North America). I’m not going to review the literature here, but a couple of good references (and yes, these are old ones, but still relevant) are Turk and Okifuji (1998), and Okifuji, Turk & Kalauokalani (1999), and of course, Main and Spanswick who wrote the book Pain Management: An interdisciplinary approach (2000). A more recent edition of this book has been published, further extending the application of the biopsychosocial model in pain management.

When we’re trying to identify what constitutes an effective interdisciplinary team so we can perhaps develop it more quickly, or refine it, the elements that make up a good team become incredibly complex.  The individuals themselves, the communication style, the procedures that structure their work, the roles people play within the team – all of these elements need to be understood to work out how a good team becomes more than the sum of its parts.

Humphrey, Morgeson and Mannor (2009) produced a paper outlining a theory that considers not just the individuals and the roles they play within a team, but also the composition of the roles.  Recognising that not all roles are made equal, in this paper they look at what they call ‘strategic roles’ – those roles that either encounter more problems, or are more involved in critical activities, or are in a central position in the workflow of a team.  This definition describes strategic roles according to the structure of a team rather than the performance of a team.

They then looked at a number of teams (OK, they used sports teams, but the model can apply to health teams too), and identified that it is not the individuals within a team, but the roles they fulfil in a team that make a difference to the effectiveness of a team.  Some roles are more important to the outcome than others.  They then suggest that by investing more heavily in the ‘core roles’ of a team, overall performance increases – this investment could be in terms of resources available for the people fulfilling these roles, or rewards for those individuals in this role, or time available to the people fulfilling those core roles.

Another facet to this study looked at the place of experience and skill on team performance – it matters who has experience depending on the roles that person fulfils.  This suggests that investing time, training and possibly even monetary reward for those people who fulfil important or core roles could pay dividends in terms of output or outcome of the entire team.

Interdisciplinary teams are complex beasts.  While most of us work within some sort of team, many of us don’t know what our contribution actually does within the team.  And most of us haven’t been trained in how to work effectively in teams – after all, our training has been primarily to develop our individual professional skills, rather than to recognise the strengths of a collective.  Perhaps this is an area for us to explore in more detail – and maybe managers can learn from research such as Humphrey, Morgenson & Mannor’s team roles theory, and look at how to resource team members to enhance their work.

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Humphrey, S., Morgeson, F., & Mannor, M. (2009). Developing a theory of the strategic core of teams: A role composition model of team performance. Journal of Applied Psychology, 94 (1), 48-61 DOI: 10.1037/a0012997

Okifuji AA, Turk DC, Kalauokalani D. Clinical outcomes and economic evaluation of the Multidisciplinary Pain Centers. In: Block A, Kremer EE, Fernandez E, editors. Handbook of Pain Syndromes. Mahwah, NJ: Lawrence Erlbaum Publishers; 1999. pp. 77–97.

Turk DC, Okifuji A. Treatment of chronic pain patients: clinical outcomes, cost-effectiveness, and cost-benefits of multidisciplinary pain centers. Critical Reviews in Physical and Rehabilitation Medicine. 1998;10:181–208.

Talking about roles in pain management

If you’ve missed it before, you won’t in the future: I don’t like turf protection in pain management!  If there is one thing people experiencing pain really need, it’s consistency from all the people working with them – and the second thing they need is more people doing good pain management.  So IMHO there is no room for health professionals staking out an area and saying ‘its mine all mine’.

Nevertheless, there are certain areas of greater or lesser specialisation, and I’m not suggesting pain management becomes an area like many mental health ones, of generic ‘case management’.

What I am suggesting is elimination of the phrase ‘the [insert professional title here] role in pain management is…’ What I’d like to suggest is a new way of looking at what each professional does, and the phrase ‘what [insert professional title here] can offer a team is…’ (more…)

What happens when you can’t do what you want to?

Intendus interruptus, or ‘I want to but I can’t do it’

There is no doubt that having chronic pain stops many people from working towards things they want in their life.  At least for some of the time, especially during the early phases of their experience, people tend to focus on obtaining a diagnosis, then either a cure or some form of pain reduction.  Comments from people during this time are ‘I put my life on hold’, ‘I’m just focusing on getting through each day’.

What we then see, as chronic pain persists, is a gradual reduction of engagement in firstly leisure activities, then work activities (however you construe this), and finally self care activities. Over time, as Paul Karoly puts it, they develop ‘… a self-defeating reappraisal of one’s everyday goals and aspirations in light of the unabating discomfort and pain.’ (Karoly & Reuhlman, 1996) We see this as deactivation, demoralisation and reducing levels of function. (more…)

The two faces of pain assessment

This week’s focus is on assessing or evaluating or getting to understand the experience of pain.  There are many reasons to assess someone’s pain, from trying to diagnose the kind of pain they have to attempting to see if someone is ‘real’ or not!  And shades in between.  I’m going to focus on ‘genuine’ reasons to understand someone’s pain experience rather than policing whether the person is a good actor or not, because as I’ve said before, I don’t think very often about people ‘faking’, and because I think it might be more helpful to try to see the world from the person’s eyes first.

So, given that pain is a multidimensional experience, why do I say there are two faces to pain assessment? Well the two I’m thinking of are:
(1) the experience of pain itself – location, quality, intensity etc, along with the beliefs and risk factors that influence the ‘suffering’ component of the ‘onion ring’ model described by Loeser and others.
(2) the impact of pain on function – disability, sleep loss, effect on relationships, work and so on.

I’m going to leave the first aspect for a while, and spend some time looking at the impact of pain on the individual and his/her family/community, but before I do I want to consider some basic concepts relevant to pain assessment that are essential before even beginning to think about the ‘how’ of assessment!

Firstly, all pain assessment is subjective. What that means is that as outside observers, we cannot determine whether the person is actually experiencing what they say (or indicate) they are experiencing. We can’t reliably establish whether someone is or is not carrying out activities to their full capacity. We can’t accurately determine whether a certain number of pain behaviours is the ‘correct’ amount of behaviour for the amount of nociception present.

Secondly, all behaviour is subject to the effects of learning and reinforcement that are well-established in the psychological literature (and in any two-year-old child wanting sweets!). As a result, it’s difficult to tell whether someone is behaving in a certain way because of years of learning within their family context, or whether it’s more immediate social environment demand characteristics that are influencing how the person is performing. We would all probably do more for someone that was holding a gun to our heads than for someone who looked bored (and we knew the results were going to determine whether we got some money!).

Thirdly, what we will or won’t do is also influenced by what we think we can or can’t do – and what we anticipate may happen afterwards, or what we experienced last time we attempted. A recent study of functional capacity evaluations found that even for people without chronic pain, a majority of participants experienced elevated pain the day after completing an FCE, so my guess is that some people who have chronic pain and who have completed a previous FCE may modify their performance at the next one. Our beliefs, attitudes, predictions, memories and so on determine what we are prepared to do in any context. When we look at the impact of pain on function, we need to remember this and take these factors into account.

The final area to consider today is the effect of context on performance. In many ways this is a summary of the three previous areas I’ve mentioned, but bear with me as I explain.
Many people with chronic pain report that they can carry out an activity in one setting, once, but when asked to carry it out repeatedly, and in a work setting, for example, they struggle. In the context of the real world, with all the social cues, cognitive load and need to persist and maintain activity over time, performance becomes variable. This doesn’t just happen for people with persistent pain mind you – let’s think of those Olympic athletes who may have performed well ‘at home’, but in the context of The Olympic Games in China in Front of All Those People – performance may well be very different.

I’ve only mentioned a few of the confounding factors that influence how pain may impact on a person’s daily activity in life and roles. I haven’t even started to use references – but you can bet if you come back this week, there will be more!

It’s not rocket science – it’s respecting the individual

Using cognitive behavioral therapies in pain management isn’t really rocket science, it’s simply being aware of the principles of learning from both a cognitive (thinking) point of view and a behavioural point of view. It is, however, complex – by that I mean, there are many threads to systematically follow and actively manage.

There does need to be a fairly large emphasis on assessing or understanding (or formulating, if you prefer psychological language) the factors that are working together to influence the person’s presentation. A formulation is simply a set of premises or hypotheses that, if they are tested and found to hold true, help to explain why this person is presenting the way they are, and to predict how they might respond in certain situations.

In chronic pain management, this means incorporating biophysical or biomedical elements, along with psychological and social elements. The complex blending of all these factors is what gives each individual a unique presentation and a unique set of concerns. And this is why it’s important never to think there is a ‘standard’ or routine way to help people with chronic pain develop ways to cope and move forward. ‘Cookie cutter’ or ‘recipe’ methods simply won’t work as effectively as an individualised approach.

My main concern currently is that the biomedical/biophysical and psychological aspects of assessment are fairly well covered in many settings – the aspect that is least well assessed and addressed is the social. ‘Social’ covers an area of influence that begins with interactions between the individual and his or her family, through to the influence of mass media and systems of governance and policy within a society. I think in New Zealand anyway, the psychological assessments are becoming over-emphasised, and the lack of emphasis on roles, function, interactions

Today let’s look at the words of people experiencing chronic pain – a great reading is Mandy Corbett, Nadine E. Foster, Bie Nio Ong’s paper ‘Living with low back pain—Stories of hope and despair’.

It incorporates the narratives of six people experiencing chronic pain, and themes that emerge include the fluctuating emotions of hope and despair. A number of linked themes emerged which influenced the extent to which people oscillate between hope and despair, the most salient of which were ‘uncertainty’, ‘impact on self’, ‘social context of living with pain’, and ‘worry and fear of the future’. It is clear from the narrative accounts that it is not only just physical pain that the back pain sufferer must endure, but also that the psychosocial implications pose an added and often complicated challenge.

‘They [others with back pain] go through what
I’ve been through. They’ve got to come through
it all: the stress, the anger, er…the feeling of uselessness, and it can take a toll on a
marriage and a family so bad, to the point that,
that person may not have a family in 18 months,
four years’

‘You know, I can’t have one
day a week off. I’ve got to do full-time and I’m
finding it very hard and I’m frightened that I’m
going to do it because I have to, but then I end up
getting worse and I just can’t cope. What do I
do? Because that worries me. I can’t go off sick. I
can’t afford to go on half pay. So .. so that’s a
real dilemma.’

‘He positions himself as a social persona
who contributes both to his family and to the
community, and re-affirming himself in this way
forms the foundation for a generalised hope where
he can have faith in the future’

Can we spend a while listening to the social context of the people we work with? Considering both the impact and the influence of the wider social factors that abound when an individual experiences their personal pain.

More tomorrow on the social context of pain.

Corbett, M., et al. Living with low back pain—Stories of hope and despair. Social Science & Medicine (2007), doi:10.1016/j.socscimed.2007.06.008

Effects of disability – diathesis-stress

I’ve posted before on the effects of disability that make coping a challenge – today I want to cover a few more areas. My aim is not to suggest a ‘poor me’ attitude towards people with chronic pain, but instead to highlight how these demands might affect core beliefs. This is an important area for clinicians working with people experiencing chronic pain, because sometimes our well-meaning recommendations to, for example, work to quota, try exercising, or use relaxation, can fall flat – not because they’re the wrong recommendations, or the person is ‘not motivated’, but perhaps because the strategies cut across the person’s beliefs and attitudes. By sensitively exploring why a person isn’t keen on adopting a specific approach, we can help them gain awareness of their own process of adapting to their disability, and perhaps gain their trust and help them try a new skill.

A theme throughout the thoughts on disablement is loss of control and loss of acceptance – the two foundations for what in our culture we think make a complete person. To lose control means we are helpless and powerless and have no voice. To lose acceptance means we don’t belong, we are somehow not worthy. And because many of us have never really taken time to check in with our fundamental beliefs about ourselves and the world, when we are challenged with disability, it may rock these assumptions, and provoke distress right in the areas we feel most vulnerable. This is the diathesis-stress model where any area of vulnerability, when stressed, can become symptomatic.

Loss of control
Feeling in control is a really strong part of being human in New Zealand society. We expect each other to be in control emotionally, to control our body functions, to ‘hold it together’ when we are challenged. Tears are just not acceptable in business – and only just in sports!
Some of the effects of pain itself mean that a person feels no longer in control of choices, but what can be more challenging than this is the effect of having to attend appointments, the side effects of medications, trying to be understood in a language that is unnatural (our health care jargon!).

Loss of resources
Practically speaking, people who have restrictions in their ability to carry out activities often also have restrictions around their ability to work – and additional costs associated with mediating both their disability and the medical condition contributing to it. As a result, many people experience material losses in income, interpersonal losses in terms of relationships within the family, workplace, and intrapersonal losses such as loss of self esteem, self efficacy, energy.

Although some of these costs can be offset by central government initiatives (subsidies on medication and health care), or by insurance or compensation (income and treatment costs), many cannot be compensated adequately and some areas not at all.

Role changes
The roles we carry out form the basis of much of our self image. Even temporary loss of function can mean an alteration in the roles we can carry out. In the short-term, people around us can be quite flexible and make allowances for these changes. Over time, however, and especially when the disability is ‘invisible’ such as with pain, people can become much less comfortable with making these adjustments, and the effect of both external pressure to ‘step up to the mark’ and internal pressure to fulfill expectations, can lead to stress and conflict. Some of these changes can be positive, for example many people do appreciate the opportunity to spend more time with their family when they first stop work, and this can be challenging when change or recovery is evident. Despite this, most people would acknowledge that role losses associated with disability are greater than role gains.

Life, the universe and everything
At some point in our lives, we will directly face our mortality. Some of us will only recognise this a moment before our lives end, but people experiencing chronic pain and disability often feel their own end of life well before it actually ends. While some people are reasonably comfortable with this process, others are very fearful and it’s not a topic that is often discussed openly with someone who is not given a diagnosis that suggests death. Yet people often wonder about the possibility of dying from their disorder – or contemplate suicide as a way to end their suffering. We need to be mindful of this in our clients, whether or not they present as being depressed. We can at the very least acknowledge that at times it does pass through the minds of our clients.

While many occupational therapists and physiotherapists don’t feel confident or comfortable about discussing suicidal thoughts with their clients, it remains an important area to take into account. If need be, seek some further training to develop the ability to discuss this with your client. Even more importantly, consider what your own concerns are around discussing this with your clients. What are your automatic thoughts? What are the underlying beliefs, rules, attitudes that influence your responses? I’ll cover how to assess and respond to suicidality in a separate post.

Doctors, nurses, and other health care providers
If there is one place I really dislike, it’s hospitals and the health care system! And once a person has a diagnosis, and starts to receive health care, they’re enmeshed in a system that is both foreign to many, and almost incomprehensible even to people who work in the area! So it’s no wonder that people can feel frustrated, alienated and powerless, especially when they’re feeling vulnerable about their own body integrity, and are anxious and perhaps overloaded with information.

Part of the problem is that no single person, including the patient, has all the information assembled in one place! It’s almost like a game of whispers. While communication is always heralded as Most Important, it doesn’t seem to happen consistently enough. At the very least we should gain consent from the person to share relevant information, and always include the person in any sharing of information.

I don’t think the areas I’ve touched on today are particularly new or earth-shattering – but they do demonstrate the amount of work that people who have chronic pain need to put into their wellbeing just to get to the point that many of us as health care providers accept as ‘normal’.  Let’s not forget these challenges when we start to think about ‘pushing’ our clients to do more…

I’m heading off for a couple of days to the Wild West Coast of New Zealand.  It’ll be a fun weekend at Lake Mahinapua, which is just south of Hokitika.  So I’ll post a couple of nice photographs from my last trip to keep the hook baited! There will be more shots after the weekend – don’t forget you can always visit my Flickr pages if you want to see some of what I do for my relaxation!