Research and practise – relevant?

This week I want to focus on research.  A couple of events brought this up for me:

I spent some time with Margaret Morrell, professional supervisor and trainer in supervision on Friday.  She raised the thought with me that many practitioners (from any field) don’t routinely question what they do and why. Her view is that supervision provides a forum for this to happen – so that people can continue to develop as a professional, and to routinely bring criticism and questioning into their practice to be the very best they can be.  I was a bit stunned when she said this – I can’t remember a time when I didn’t routinely question what I do, how I do it, why I do it and want to be challenged, but it seems that there are those therapists who simply follow the ‘rules’ and act more as technicians than professionals.

This is a real problem for patients who don’t know the practice style of the health professional they are seeing – how do they know if the therapist they are seeing is simply doing what he or she has always done, or whether their practice is routinely informed by recent research developments?

The second event to raise this issue with me was via the SomaSimple forum where someone pointed out that there are people who question their profession over and again, and there are people who are satisfied with doing what they’ve always done.  There are people who can’t answer the question ‘why does it work’ – and worse than that – they don’t care.  And this means our therapy can’t move past holding onto ‘comforters’ or things that seem reassuring even when they may not stand up to the cold hard light of day.  I wrote about this recently when talking about occupational therapy and the ‘myth’ of ‘activity is good’.   It may be that the belief that activity is good is demonstrated empirically to be sound, but until then it’s simply a belief.

By coincidence, I received a contents list from the journal ‘Rehabilitation Psychology’ which has a complete issue on Methodological Advances and Issues in Rehabilitation Psychology.  While this issue is mainly about psychology in rehabilitation, it has so much application to rehabilitation in general, I think it’s worth exploring.
Here’s the abstract from the editorial from the journal:

Scientific research plays an important role in advancing the knowledge base of rehabilitation psychology. Research contributes to theory building and provides the foundation for empirically supported rehabilitation psychology practices, and model-based diversity-sensitive evidence-based interventions help persons with disabilities to become fully integrated into the society. Objective: In this article, the guest editors present their rationale for developing this special issue on methodological advances in rehabilitation psychology. Conclusions: They suggest that rehabilitation psychology research needs to be theory driven using rigorous research designs, strategies, and techniques and describe their selection of articles designed to highlight some exciting new developments in rehabilitation psychology research and to stimulate thinking and facilitate discussion about incorporating these new techniques in theory-driven research programs.

You know, that doesn’t sound so very different from arguments about using research in any field of human endeavour.  Perhaps it’s tainted a little by the drive to have a theory-driven approach, using rigorous research designs – I mean, where is the place for human judgement and expert opinion??!  (sly reference to this post where I reported that psychometric data predicts more accurately than clinician opinion…)

Is research relevant to practise?  Well yes, of course – if you ask me.  Sadly, some others in my field of pain management might say ‘yes, but’… .

I mean it does take time to read the literature.  It does mean holding a lot of information in your head and comparing your current practice with what the literature is coming up with.  It does mean critiquing research to establish whether it has application beyond its study scope.  It means working out irrelevant from relevant information, it means never taking something at face value, it means being prepared to change practice from what was learned as ‘truth’ all those years ago in training.  It can mean being unpopular when it becomes important to disagree with people who are vocal or ‘senior’ or happy to do what is palliative and doesn’t challenge patients.  It is such hard work!!

Ask yourself today: have I reviewed the treatment of a patient recently?  Have I checked in with the latest evidence for or against the model I use in my practice? Do I use a model, or do I ‘follow the rules’ as a technician might?

More on research and practise – and some practical stuff too – tomorrow!

Science and therapists

I’ll admit I’ve been warped a little by psychologists. No, I haven’t learned to blame my parents for how I’ve turned out (that’s why my mother wouldn’t let me study psychology when I left school!), but psychology as a field of science has definitely made me more thoughtful and critical of how I make clinical decisions – and opened up a whole approach to therapy that I’ve adopted and integrated into my practice.

A strand of thought in clinical psychology is the ‘scientist-practitioner’ model, promulgated in the Boulder, Colorado Conference of 1949 (and argued about ever since!). This model basically proposes that clinical psychologists need to adhere to scientific methods, procedures and research in daily practice.

To quote directly from the Wikipedia entry:
Core tenets of the Scientist-Practitioner model include:

* delivering psychological assessment (Psychological testing) and psychological intervention procedures in accordance with scientifically-based protocols;
* accessing and integrating scientific findings to inform healthcare decisions;
* framing and testing hypotheses that inform healthcare decisions;
* building and maintaining effective teamwork with other healthcare professionals that supports the delivery of scientist-practitioner contributions;
* research-based training and support to other health professions in the delivery of psychological care;
* contributing to practice-based research and development to improve the quality and effectiveness of psychological aspects of health care.
(this is an excerpt from Shapiro, 2002)

How does this play out for me in my clinical practice? And how does this differ from the ‘Problem-solving Process’ I was trained in during my occupational therapy training?

The occupational therapy process involves identifying problems, finding solutions, choosing a solution, implementing the solution, reviewing the outcome. I don’t really have a problem with this except that it omits the critical parts of setting the problem in context and developing a set of competing hypotheses that are systematically tested until the best explanation for the ‘problem in context’ is found.

These two parts are the two I’ve adopted from the scientist-practitioner model. The importance of identifying who has the problem and what the problem is cannot be over-emphasised, and neither can the process of reviewing the context of the ‘problem’. Sometimes the ‘problem’ isn’t actually a problem for the client, but rather, for someone else in the healthcare team.

Let’s unpack that with an example: I was asked to review the case of a woman who had mobility problems after an accident, and who had been assessed as needing a new vehicle so she could get out in the community. The problem was framed as her need to be able to independently drive in and around her community, and the contributing factors were her limited range of movement in her legs, obesity, and pain. She couldn’t sit for longer than 10 minutes or so, but moved very slowly and heavily using a walking frame. She couldn’t rotate around her spine, and she found bending forward difficult.

She had been prescribed a new vehicle because she couldn’t get in and out of the old vehicle she had. She’d recently had a new flat area bathroom installed, had rails throughout her house, a special chair for her in the lounge, and a kitchen that was modified and had a stool for her to perch on with a higher-than-normal benchtop so she could use it from the stool.

What was the problem? The functional problem was that she had trouble getting in and out of the car.
The solution? Get a new car!
BUT then I came in and started reviewing a few things…
What were the contributing factors – although I’ve already alluded to her mobility problems, and obesity, I haven’t revealed that her main problem was low back pain that she developed several years ago when she was involved in a car crash. She has gained weight since the crash, and is now morbidly obese. She has neuropathic pain over her right lower leg, and also has very thin skin that is easily damaged as she has asthma and has been using steroids for many years.

Contextually? This woman lived alone, but had many hours of home help. She had some strong beliefs about her pain, her accident, her right to compensation, her need for support, and her need for home modifications. She had never participated in any pain management programme. She believed her pain should be ‘fixed’ and she was angry that it had not responded to surgery or other medical interventions. The case manager was irritated that this woman had received over $40,000 in assistance not including earnings compensation, and was concerned that although a new vehicle might be nice, it wasn’t entirely necessary. The case manager thought that modifying the old one would be sufficient.

Let’s put this together.
Here is a woman with a range of beliefs about her entitlement to compensation, a passive attitude to rehabilitation, a system that had provided her with modifications to her house, but had never been exposed to therapy to review how she managed her pain, how to improve her mobility, how to reduce her weight, or even how to cope with the range of emotions she experienced since her accident.

I would lay good money down and bet that every clinician who saw this woman thought they had her best interests at heart. They were solving her immediate problems, and she was entitled to what she had been prescribed. The housing modifications and recommendations for vehicle and home help were all within normal entitlements – and clinically appropriate…
and in this case it’s a VERY big BUT
Although they served to ‘solve the problem’ in the short term, they didn’t help at all in the long term.
Sadly, by providing this woman with ways to avoid confronting her pain and learning to manage her pain effectively, and work through her thoughts, beliefs and attitudes, she had been strongly encouraged (and undoubtedly inadvertently) to remain passive in her own rehabilitation, to fear her pain, to reduce her mobility, and to remain very disabled.

So, where does the science come in?
I think one of the first things therapists need to do is review the reason for referral and be mindful of the bigger picture – in other words, the context. I think the scientific method as depicted in the hypothetico-deductive model misses out on the process of discovery which is all about looking at the bigger picture and seeking patterns.
The pattern evident in this woman’s presentation is that despite receiving all this assistance, she was not becoming any more independent. In fact, she was becoming more dependent on all the modifications and equipment she had received. This would be appropriate if she had a deteriorating condition like multiple sclerosis, but definitely NOT when it comes to chronic pain.

The clinicians also needed to review the science of pain and pain management – what are the evidence-based approaches to helping people become independent with pain management? Equipment prescription and housing modification receive very limited support in the literature.

Clinicians also need to review their basic science – how are behaviours maintained? How do we encourage change? What do we know about how people learn? Reviewing this would have meant this woman might not have had her requests for more and more help reinforced by receiving help.
And it might have been useful for therapists involved with her care to review the long-term effects of providing equipment – OK for short-term needs, not OK for long-term health maintenance.

A problem for many therapists is the lack of critical thinking – why was this referral made? Who has the problem? What alternative hypotheses could be considered to help her?

Being client-centred does not mean being client-directed. This woman would not have identified that she wanted to manage her pain better – she simply wanted it gone, and she wanted a new car so she could go out and about. What no-one seemed to have asked was how she was going to get around the places she drove to!

Being really client-centred would have involved working with her to review all the factors in her presentation, and recommending an evidence-based intervention: good cognitive behavioural therapy for pain management, gradual reactivation, therapy to help her manage her distress and anger over her condition, and possibly even a move to accepting pain instead of resenting it.

Science is about systematically observing and questioning everything – building on current knowledge and context, and coming up with new hypotheses for testing until finally a ‘useful explanation’ is arrived at – ready for the next, deeper discovery that can provide an even more ‘useful explanation’.
‘Useful explanations’ are not necessarily ‘true’ – they are just helpful, explain the majority of the presentation we see, help make predictions about the future, and make the least number of assumptions. The problem with the previous therapists approach for this lady was that they used an outmoded explanation that didn’t fit with the context of her presentation, and didn’t account for many of the contributing factors.

And that’s why I’ve adopted the scientist-practitioner model – because it continually asks the questions: Why? What’s going on here? How come? What would happen next?

For some more readings about science, I’ve really enjoyed the following:

Renewing the Scientist Practitioner Model D. Shapiro, 2002

Bob Dick’s unpublished paper discusses whether it’s time to review the model

Terry Halwes paper on Truth in Science – and the section about Western Science whcih is about 2/3 down the home page

And finally, a book I’m enjoying on ACT, or Acceptance and Commitment Therapy, for anxiety – but equally applicable for pain:
New Harbinger Publications produces a range of science-based self help books. I looked on my desk and I have four sitting there without me even looking! The Mindfulness & Acceptance Workbook for Anxiety is the latest one I’m enjoying. I started by looking for a relatively simple book on how to introduce mindfulness and acceptance to people experiencing pain. I already have the Living Beyond your Pain ACT book, but it doesn’t quite hit the spot for my clients. So I’m hoping to take extracts from both to develop something helpful for the people I work with – something a little less wordy and abstract. Not easy, but that’s me!!

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