self help

Self management: Helping a person become their own healthcare expert

and how we can help

Health care in many places hasn’t moved an awful lot from a ‘patch ’em up and send ’em out’ mentality.  This is a great approach if you’re basically healthy, have acute appendicitis, and a quick recovery.  It’s not so good if you have chronic pain, are having to learn to live with it, and find your general coping is compromised.

Most of our health care training, however, is designed to follow the medical model (despite arguments that occupational therapists, for example, are trained in a biopsychosocial model – just watch what happens when a referral for therapy is received without a diagnosis!).  There is nothing fundamentally wrong with the medical model when it’s being used in the right place – it’s simply inadequate when the health problem can’t be ‘fixed’.  And the problem with our health care training is that it’s focused primarily on ‘diagnosing’ deficits, patching them up (or compensating for them) and hoping the person will get on with it. (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…)

The Pain Survival Guide: how to reclaim your life

For my final (for now) review of self-help workbooks, I’ve chosen one written by one of the most influential researchers and clinicians in pain management, The Pain Survival Guide: how to reclaim your life, written by Dennis Turk and Frits Winter. It’s also not published by New Harbinger, but instead by the authoritative American Psychological Association.

This is a very readable book and its smaller format (than most of the other workbooks I’ve reviewed) makes it a little easier to carry and keep close than many. Despite this, it packs a lot into its over 200 pages, and it certainly contains the majority of the topics that you would expect in a self help book.  It’s broken into ten ‘lessons’ or chapters, designed to be read and followed on a weekly basis. Each chapter focuses on a single concept but refers back to previous chapters and activities, and it provides many ‘learning activities’ to help tailor the approach to the individual.

It has many self-learning worksheets that help the reader to learn more about how the concept being discussed applies personally, and although they are not as expansive in terms of room to write, they are relevant and clear.

Chapters include topics such as:
1. the need to become your own pain management expert
2. activity, rest and pacing
3. learning to relax
4. ways to combat fatigue
5. don’t let pain ruin relationships
6. changing behaviour
7. changing thoughts and feelings
8. gaining self confidence
9. putting it all together
10. maintenance and setback planning

Again, like the workbook I looked at yesterday, it assumes that people reading it are ‘ready’ for action – so no discussion about readiness for change. However, it does emphasise the need to integrate not only the pain management strategies into life, but changing goals and working with others to help return from ‘patient’ to ‘person’.

Aspects I liked about this book – it’s simple, but quite comprehensive. The writing style is easy to read (although probably more difficult than many of our clients could manage), and it doesn’t use too many ‘americanisms’ or jargon-filled sentences, so it’s palatable to New Zealanders! I’m very familiar with the approaches suggested through the book, also the order in which the chapters are presented, in which coping strategies and activity planning are provided first, then behaviours and thoughts are considered later. I also liked the emphasis on relationships and fatigue which are often neglected in this type of book.

Aspects that I didn’t think were so good – as I’ve said before, and will say again, lots of words make it difficult for the people I see to use a book like this without support from a health professional. It’s not as spaced out as some of the other books, so could be a little more difficult to use. It does cover a lot of information, so it can be once-over-lightly in some senses.

In summary – this is a good, sound self help workbook that has a behavioural emphasis that some workbooks don’t have, and a focus on the ‘real world’ which includes sleep, relationships and even having fun!

I like the readable style, and for me single chapters can be stand-alone for some clients (especially the activity planning one!). I’d see it as a book to keep on your desk, perhaps available for loan, and definitely as a support manual for anyone who is participating in an Activity Focused Programme with therapist input.

The major lack in all the workbooks I’ve reviewed is absolutely no attention to the impact of pain on work, and no discussion of how you might use the skills in a workplace where working despite fluctuations of pain is essential. Maybe this lack is an opportunity for someone to develop a workbook that does address this area?

The Pain Survival Guide
How to Reclaim Your Life
By Dennis C. Turk, Frits Winter
Format: Paperback, 203 pages
Published In: United States, September 2005
Publisher: American Psychological Association (APA)
ISBN: 1591470498
EAN: 9781591470496

Managing chronic pain: A CBT approach

Scintillating title, but accurate! This workbook is a skinny one (just 83 pages), and it’s not from New Harbinger Publications! It’s actually from the esteemed Oxford University Press, and is one of quite a few self-help books that this publisher produces in the series ‘Treatments that work’. Written by John Otis, who is an Associate Professor of Psychology and Psychiatry at Boston University, this book has to be the leanest and simplest version of all the workbooks I’ve seen. It’s also the only one I’ve found so far that has an accompanying therapist manual, which is handy – however, for the cost-per-page, this has to be the most expensive one of the workbooks I’ve found too!

The chapters in this workbook include:
1. Education on chronic pain
2. Theories of pain and diaphragmatic breathing
3. Progressive muscle relaxation and visual imagery
4. Automatic thoughts and pain
5. Cognitive restructuring
6. Stress management
7. Time-based pacing
8. Pleasant activity scheduling
9. Anger management
10. Sleep hygiene
11. Relapse prevention

So you can see, it covers the majority of fundamental self management skills for chronic pain, and while it doesn’t overwhelm with vast amounts of information, it certainly contains the critical elements.

The therapist manual provides some additional supporting information and references to further readings, and also provides ways to vary or extend the skills and strategies provided in the workbook.

What I liked about this workbook is its brevity and clarity. It doesn’t provide a huge amount of information, and it doesn’t go into detail – it’s clearly meant to be used alongside input from a therapist. It has plenty of space for individualising aspects, including a number of very clear worksheets, and specific learning activities for between each clinic-based session. I also liked the layout which is very simple and clean, and although it doesn’t have diagrams, it does have good examples and bullet-point summaries.

I also liked the specific chapter on relapse prevention, something that can be problematic for many.

What I thought wasn’t quite so helpful is that this workbook is definitely one you would need to work through with a client. While there is less detail in it, so non-readers would probably cope better with it than the other workbooks I’ve reviewed, there is still a lot of reading and writing to do. It assumes the person is ‘ready’ to take action, rather than ambivalent, and it assumes also that the person can and will integrate the skills – and then go ahead with ‘normal life’. It doesn’t focus on long-term ‘life’ goals, and it doesn’t emphasise reconceptualising yourself (the client) as a person rather than a patient.

Overall, I think this book is a real asset for therapists seeking a summary book they could provide to clients to refresh their memories after having completed individual or group sessions. While it’s not detailed, it does emphasise the things that seem to be associated with improved function – especially the ‘homework’ aspect. It would be best paired with a functional approach, and like every other workbook I’ve seen so far, it doesn’t even touch momentarily on returning to work and whether these skills can be transferable to the workplace. It also focuses on control and containment rather than acceptance and mindfulness – so for some people it might not be the best approach.

Managing Chronic Pain: A Cognitive-Behavioral Therapy Approach Workbook (Treatments That Work) (Paperback)
by John Otis (Author)
Paperback: 96 pages
Publisher: Oxford University Press, USA; 1 Workbook edition (September 24, 2007)
Language: English
ISBN-10: 0195329171
ISBN-13: 978-0195329179

Managing Chronic Pain: A Cognitive-Behavioral Therapy Approach Therapist Guide (Treatments That Work) (Paperback)
by John D. Otis (Author)
Paperback: 128 pages
Publisher: Oxford University Press, USA; 1 edition (September 24, 2007)
Language: English
ISBN-10: 0195329163
ISBN-13: 978-0195329162

It’s about $80.00 for the therapists book, and about $40 for the workbook – not cheap, but discounts for multiple purchases may apply if you ask nicely!

Living beyond your pain – an Acceptance & Commitment Therapy approach to pain management

Well, that was a title and a half!
Yes, today’s review is about Living Beyond Your Pain, a workbook written by Joanne Dahl & Tobias Lundgren, with a foreword by the ubiquitous Steven Hayes, and yes, it’s published by New Harbinger Publications (again!). I want to promise, with my hand upon my heart, that I’m not in their pay-packet, and I will review something published by someone else very soon!!

Anyway, this book is based on the ACT model, which suggests that rather than trying to control your thoughts or the uncontrollable (your chronic pain), it’s preferable to live aligned to your values, and bring pain along for the ride. By neither focusing on, nor ignoring pain and judgements about your pain, it’s possible to take committed action and do valued activities instead of avoiding activities because of your pain.

Initially the ACT approach can be a little difficult to grasp, or at least that was my first impression. After reading quite a lot including the Association for Contextual Behavioural Therapy website, I have learned a bit more about it, but I still think the description in Living Beyond Your Pain is a basically sound one. Not easy to understand – but perhaps that’s because the approach itself is so different from the standard CBT approaches.

The workbook is, like all the other New Harbinger Publications books, well-designed with lots of white space, clear layout, and plenty of space for personalising and completing activities throughout.

It starts with establishing that most other strategies have not worked – creating a concept that I like of ‘creative hopelessness’ or ‘positive surrender’. To a Western audience, the very idea of surrendering or losing control to something that is unwanted is quite a strange idea, but as the authors in this workbook point out ‘Have you ever come to a point in your struggle with pain where you simply said ‘I can’t fix this’? What did that feel like? You may have experienced some grief, but wasnt there also a certain freedom?’….’We define creative hopelessness as a place where new possibilities for changing your life arise.’

Like most of the other workbooks, it also has chapters on ‘what is chronic pain?’, awareness of thoughts – and distinguishing between thoughts and the person thinking the thoughts. In terms of skills, the book covers the practice of ‘mindfulness’. This originally buddhist practice involves becoming immersed in sensations happening NOW rather than thinking about, recalling, predicting or even labelling the experiences. It is a meditation practice, but in this book it’s described as becoming a ‘watcher’ or ‘observer’ of your own thoughts – and not judging or evaluating your experiences or thoughts.

The workbook also, and very importantly, covers the ACTION part of the ACT practice. Not only is mindfulness used, but acting according to what is important or valued – and sticking to that action. By being appreciative of why you want to do something in a positive way is a much more enjoyable experience than gritting your teeth and ‘just getting on with it’.

Finally, the book finishes with ways to maintain action, and how to face barriers that are certain to be in the way of making forward momentum.

The strengths of this book are, like all New Harbinger workbooks, great layout, authoritative authors, the individual learning activities all the way through so the content is readily made relevant to the individual, and the use of a relatively new approach to living with chronic pain. Some of the activities, especially around ‘values illness’ and what people have given up to avoid experiencing pain are particularly profound and challenging when used with people who have chronic pain, and can be very persuasive for helping people consider what is important in their lives.

What I found less helpful was the slightly complex and convoluted way that ACT was described (mind you, I haven’t found anything much easier either!), and it does require good cognitive function (these concepts are abstract). As with any workbook, the reader would have to be committed to making his or her way through the whole workbook, and it’s definitely much easier to do this with a therapist helping the process. I would also have loved some more diagrams – they really make the points so much more easily.

To summarise? I wouldn’t use this book as a first-line approach to pain management, and I think it would be very important to do some further learning around the ACT approach before starting to use this workbook with clients. On the other hand, excerpts from this book are great – especially the concept of ‘clean pain’ which is essentially about experiencing the sensations and ‘dirty pain’ which is about judgements about having that pain.

Living Beyond Your Pain
Using Acceptance & Commitment Therapy to Ease Chronic Pain
By Joanne Caroline Dahl, Tobias Lundgren
Publisher: New Harbinger Publications
ISBN: 1572244097
EAN: 9781572244092
Format: Paperback, 169 pages
Published In: United States, May 2006
Other Editions: Paperback, USA $56.99
$34.20 from Fishpond – reduced from $45.99,

Self Help Books: A behavioural assessment approach to chronic pain

Today’s self help book is published by one of the more prolific publishers of psychological self help – it’s from the New Harbinger Publications stable of self help books.

The Chronic Pain Care Workbook; A self-treatment approach to pain relief using the behavioural assessment of pain questionnaire is written by Michael J Lewandowski, a clinical psychologist with years of experience working with people experiencing chronic pain. He has developed the pain assessment tool used in the book, called the Behavioural Assessment of Pain assessment, which has been used internationally for pain assessment, and forms the basis of self discovery for people working through the workbook.

Like most chronic pain workbooks, this workbook is designed to reassure people that their pain is understandable, to a certain extent, able to be managed if not controlled or reduced, and to help people to take steps to return to a normal life. What is slightly different about this book is the extensive use of self assessment across a wide range of areas to form a ‘Pain Scorecard’ – and thankfully, there is some empirical support for the assessment norms (just not norms developed for New Zealand!). There are actually 29 individual subscales comprising areas such as Pain Intensity, Sleep Interference, Fear of Re-Injury, Pain Behaviours, several Interference scales, and several relevant to ‘significant others’ in the person’s life.

For each subscale there is a separate questionnaire, many quite brief, that are asked throughout the book – and the scores are arranged in terms of areas of strength, concern and significant concern. Subscales can also be arranged by category, and the book provides specific solutions for ‘common areas of concern’.

While it’s possible to complete all the questionnaires before reading through the book, and therefore only dipping in and out of relevant chapters, it’s preferable to work through the book chapter by chapter, reviewing each area in the order indicated. This makes the workbook a little less daunting (it’s over 200 pages long), and the chapters do flow in a reasonably logical order.

Chapters include:
Part 1 – what is chronic pain, including definitions of chronic pain, the biopsychosocial model, readiness and intention for change, baseline pain ratings and goal-setting, and a brief review of diagnosis
Part 2 – Behavioural assessment of change, including fatigue, medication, thoughts and ideas, pain behaviours, activity interference and avoidance, emotional pain, family and social, sex and intimacy, and working with the health care team
Part 3 – Conclusion – setback planning, progress monitoring, acceptance
Part 4 – the Pain Scorecard and interpretation

The strengths of this book are the individual learning activities all the way through, ensuring that for the committed reader, the content is readily made relevant to the individual. It also uses quite clear language, there is room to breath (white space!) on each page, and it’s possible to complete all the exercises within the workbook.

I also liked the reference to stages of change, personal goals (the reasons for using this workbook), and the use of both behavioural and cognitive strategies. None of the strategies are particularly new or unique, but they are very relevant and low-cost. One example is the use of blue dots placed around the environment as a cue to notice and use a brief relaxation technique. Recording charts are also included for activities that can be used on a daily basis.

The aspects I felt were less helpful was the sheer volume of information, and some of the language is probably well beyond the people I work with. Like any workbook, it’s attempting to be ‘all things to all people’, so most people would probably appreciate having a therapist work through it with them – at the very least to get all the way through it! I would also have appreciated some diagrams, or visual aids that didn’t include words – personal preference, but probably applicable to a good number of people who would want to use this type of book.

Overall? A helpful workbook, but very in-depth, and probably would need someone very committed to complete it without support. Certainly a lot easier to read and follow than the Nicholas, Molloy, Tonkin & Beeston book I reviewed yesterday.
The Chronic Pain Care Workbook: A Self-treatment Approach to Pain Relief Using the Behavioral Assessment of Pain Questionnaire (A New Harbinger Self-Help Workbook)
by Michael J. Lewandowski
Paperback: 223 pages
Publisher: New Harbinger Publications; 1 edition (November 2006)
Language: English
ISBN-10: 1572244704
ISBN-13: 978-1572244702
It’s roughly NZ$30 and readily available.

A week of self help books!

I hope to spend a little time reviewing self help books for chronic pain management – please note I don’t sell them, I just buy them! Anyone looking in my office will realise I spend wayyyy too much time in Amazon.com, and they make waaaayyyy too much money out of me!

Anyway, a quick review of one book today – more tomorrow.
This one is a bit of a standard, Manage your pain by Michael Nicholas, Allan Molloy, Lois Tonkin and Lee Beeston. It’s readily available, not overly expensive, and endorsed by Prof John Loeser, University of Washington, Seattle.

It’s designed to be complete, includes a lot of information, and for a self help book, spends quite a lot of time looking at investigations and treatments that may be used by medical professionals. Chapters include ‘What’s going on in your body when you have pain?’, ‘What X-rays, CT and MRI scans tell us’, ‘Working with your Doctor’, and ‘Treatments for chronic pain’. Then it starts in on the good stuff – Pacing, setting goals, recognising obstacles to change, stretching and exercising, challenging ways of thinking etc.

Three observations about this book –
1. On the helpful side, it’s Australasian, so for those of us from Down Under it refers to things quite familiar.
2. On the not so good side, I found it quite text-dense which could be off-putting for so many of the people I work with who have very limited literacy.
3. The other not so good aspect is that it doesn’t include worksheets or ways to personalise the application of strategies to an individual. I think it could be quite easy to glance through the book and just not use the very helpful information that is included.

I’d suggest this book is one you might provide as a supplement to individualised input by a health professional, and perhaps set individualised goals as you and the client work through the contents. Or it may be one that is held as a reference in a health centre, with certain chapters provided to the person with chronic pain as needed.

Oh, by the way – I hadn’t heard of Fishpond online bookstore in New Zealand until a couple of weeks ago – yet another place I’ll need to lock up my credit card from!!

Manage Your Pain
Practical and Positive Ways of Adapting to Chronic Pain
By Michael Nicholas, Allan Molloy, Lois Tonkin
Format: Paperback, 224 pages
Published In: United States, September 2006
Publisher: Souvenir Press
ISBN: 0285636790
EAN: 9780285636798

A Wish List for goal directions

I’ve been posting about goal-setting, and mentioned the Wish List approach – today I can do the Big Reveal!

Thanks to my colleagues at PMC (who shall remain nameless!) I have attached a copy of the ways-i-want-my-life-to-change-wish-list that people can use at the very beginning of a programme to help identify the areas they want to influence by developing pain management coping skills.  It can be used instead of the menu I showed yesterday, or it can be used alongside it.

There are quite a lot of areas that people would like to change or learn about with regard to chronic pain, and this list isn’t designed to be exhaustive. It’s also not especially specific in terms of making measureable goals based on research into goal-setting that we’ve discussed a few days ago.

What it does do is give you, as the clinician, a really good idea of the sorts of needs the person has already identified. In terms of motivation or readiness for change, it can indicate areas that the person is already ‘contemplating’, or is even perhaps in ‘preparation’ for change. Prochaska and DiClemente’s model (oh yes, I’ve talked about this a LOT!) and work around this model clearly supports the finding that people need to be in the right space to even start to consider making changes.

If the person is never asked to consider an area that could change, though, it’s fairly difficult for them to actually decide that they would like it to be different, so part of our role is to help open up the possibility for change – and you can see this in the ‘Wish List’.

I use this Wish List at the very beginning of the programme, asking people to tick all the areas they would like to see changes in. Then after a week or so, I ask them to indicate their three most important ‘wishes’. Then we can start working on importance and confidence: why these areas are important (providing the person with the opportunity to reflect on how important it is to them, and uncovering personally-relevant values to support their change process), and how confident they are to achieve them. Once we’ve identified their level of confidence, it’s part of my work to help the person build the confidence to start taking steps towards achieving the changes they want to see in their lives.

To me, pain management is not simply about developing a set of new coping strategies that can be employed while the person continues on in their life. It’s much more about reconceptualising who they are: to move from a person who has become quite experienced at being a patient, and following other people’s requests or directions, into someone who has their own life to live, their own direction to follow and is becoming a person again.

This is why I feel quite frustrated with many self-help books, even for chronic pain, that are chock-full of new ways to cope, but leave the integration of these coping skills to the person.  Integrating new skills is critical for the skills to actually be used. If you’ve ever been to a workshop and come away with a whole set of new ideas – only two weeks later find yourself doing just what you’ve always done, you’ll know exactly what I mean!

In industrial and organisational psychology, a lot of research has been undertaken into ‘transfer of training’ – and things like ongoing support in different contexts, refresher courses, memory prompts, support from ‘important people’ (eg line managers in a factory) are all known to be both effective and almost essential before training can be implemented in a workplace. (For some good information on transfer of training, this site provides some good resources).

Now, start to think of how we as health providers, support transfer of skills developed in a clinic: how many of us get the support of the ‘important people’ in the person’s life to help them use the new skills? How often do we consider the network of relationships that are a part of an individual’s context? How could we help that person make the links between what we show them and what they can readily use in their own environment?

This is really important as far as developing pain management skills in the workplace goes. Without specific support to help someone use their skills, in the context of work where all the cues for old behaviour exist, it’s going to be very difficult for them to recall and do something different. Especially when they are perhaps not entirely convinced that this new way of working is helpful.

So while pain management itself is not about ‘personality makeover’, it is all about reconceptualising the person-as-patient into the-person-as-person. Without that essential ‘new belief’ the person will likely return to old habits.

Your challenge for today? What about taking some time to think about one method you could use to support someone to recall a skill that you are helping them develop? How could you transfer what they are starting to learn with you into their home or work situation – hey, even into their car!

Finding positive solutions

Sometimes you stumble across something that you just can’t put better than it already is… Today’s one of those days, and I’ve found a website that summarises a whole bunch of coping strategies very neatly indeed.

Click this link to go to arthritis.about.com for a great range of pages covering topics like 10 ways to improve your life, Sexuality and arthritis, Dealing with Needle Phobia, or Prescription Drug Abuse – yes, a wide variety indeed.

What’s nice about these links is the range of allied links on various topics (like the general page on phobia’s which features under the Needle Phobia page). What’s not so good is the once over lightly way in which the topics are covered.

With all of these coping strategies it’s relatively easy to learn about ‘what’ to do, but oh so much more difficult to learn ‘when’ and ‘why’ and even more importantly, ‘how’ and how to deal with the mind chatter that goes along with it all.

Head on over and click the links, but remember that there’s a reason therapists are professionals: because we do know some things at a specialist level, and our job is about applying general principles to the unique individual situation of the person we are working with. It’s that formulation and clinical reasoning that we offer that a self-help book or website will not be able to do.

For some people, knowing ‘what’ to do may be sufficient, but for others – it’s much more about learning when, why, and how to apply coping skills – the right one at the right time for the right person.