systems

Seven things that made me go ‘gggrrrrrrrr!’ in 2008


It’s the time of year to reflect and review, so today I’m going to look at some of the stand-out events and issues that got me riled.  You might, after reading these, think that a kind of theme fits these things but as I write them I promise I’m not choosing them to fit any preconceived ideas!  They appear in no particular order, either…

  1. Health professionals ‘turf protecting’ – it could be occupational therapists holding out to be ‘the only ones who do goal-setting’; clinical psychologists saying ‘but we’re the only ones who can really do CBT’; physiotherapists proclaiming ‘but only we can do talk about posture’; anyone who says ‘but I don’t want to do generic case work because I’m special’– well you know what I mean!  Enough already, there are a bunch of generic skills out there that anyone who has health professional training can and should be able to do.  Let’s get over ourselves and just do it, OK?
  2. System that focus on seeing lots of patients and generating lots of income without ensuring teams are able to provide quality treatments. In health care, it really does make a difference to the patient if the focus is on quantity rather than quality.  If we don’t spend time reviewing our practice, integrating research, developing strong teams and caring about what we do and how we do it, our patients don’t benefit.  It’s not simply about efficiency, it’s about effectiveness.
  3. Medics who can’t resist the ‘just one more’ approach. People living with chronic pain are so often on a roller-coaster of ‘it might help’ then ‘but it didn’t’ that someone at some point needs to say that it’s time to get on and live.  It is actually possible to live a full, rich, rewarding and enriching life despite experiencing chronic pain.  Reducing pain doesn’t improve the unhappy relationship, stop the job from being a dead-end one, or connect a sad person with new contacts. (more…)

On networks and silos


A brief comment this morning, as I’m struggling with sinus problems and hayfever (oh the joys of spring!).

I was thinking about the need to develop networks between groups of health providers working in different settings and different systems.  It seems sensible to me at least that we should be aware of what other providers have available within our communities – at least so we know the options for the people we are working with, even if we can’t directly refer to those providers because of funding issues.  But this is a vexed question because I work in a public facility, and traditionally the relationships between public and private facilities in New Zealand have been at arms-length.

The managers of public facilities seem to view private practices as places of lush finances where money is no object and therefore somewhat suspect.  At the same time, private facilities look at public clinics as places where efficiency isn’t necessary because there is a steady flow of money coming in from Government… (more…)

Work is the context


For many years I’ve worked in pain management and tried to help people return to work as the completion of their rehabilitation. Why? Well, apart from it being a great thing from an insurer or funder’s point of view, it’s actually what people want.

Having been through my own return to work rehabilitation after my concussion, I can personally describe some of the effects of return to work efforts – and the fears and concerns I had (and still have to some extent). However, as you know I don’t like to rely on my own personal opinion, so I thought today I’d describe the comments of participants in the pain management programme I work in.

The question participants are asked is ‘What does work mean to you?’

And their responses?
The first group of comments is that ‘work is necessary for money’, and the second ‘to get case managers off my back’ – and then some more thoughtful responses.

Here people say very clearly that work is about meaning and purpose in life, the activity that organises the day, the topic of conversation, the social interaction, the belongingness to a community, contributing to society, identity and self worth and competence.

For some interesting snapshots of what workers say (at least a group of them in the US), listen to this series of podcasts on ‘Meaning of work’. And for a slightly different take on the meaning and value of work, this community arts project by Lara Lepionka provides a wonderful doorway into the meaning of work to ‘ordinary people’.

When they are not working, participants agree that it may be fine initially, but rapidly becomes a much less positive experience. Some health researchers state that stopping work hastens ill health and death. At the very least, participants in the pain management programme agree that they don’t want to remain off work – but they lack confidence to actually return to employment.

When I read assessments of workplaces carried out by various therapists, something is missing. Each assessment covers the physical activities, the equipment, the tasks, the physical environment – but given the amount of time we typically spend in a workplace, I see very little description of some of the fundamental aspects of the culture of a workplace. More importantly, the relationships between people in the workplace are rarely mentioned.

If we return to social learning theory (remember Bandura?), and our behavioural fundamentals, we can see that responses from people within an environment are a particularly potent influence on both behaviour and belief. It’s surprising then, that assessments of the workplace, particularly when an individual is having trouble returning to work, don’t even mention attitudes, beliefs, or behaviours of the other people in the workplace. Workers spend roughly 8 or more hours in a work environment, have strong opinions about their workplace (whether they like it or lump it!), and among some of the so-called ‘black flags’ and ‘blue flags’ (see this 2002 BMJ article), the individual’s perceptions of the workplace and the organisational and task demands of the workplace feature as risk factors for people to fail to return to work.

Even in comprehensive pain assessments, although mention is made of work and past working history, mention is rarely made of the person’s belief about whether they will return to work (which is probably one of the most predictive questions for RTW I know of!), and even less of the employer-employee relationship or the social-cultural and organisational factors in the workplace.

There are multiple reasons for people having difficulty returning to work. One of the most commonly cited reasons, given by case managers, employers, and treating clinicians is ‘lack of motivation’.
It’s time to deconstruct ‘motivation’ and explore what motivation consists of – if we follow Prochaska and DiClemente’s Transtheoretical Model of Change, it’s made up of two major components: importance and confidence.

People are ambivalent about moving forward because the ‘good things’ about change are balanced by the ‘not so good things’. In returning to work, the ‘good things’ are all those reasons given by the participants in the pain management programme. The ‘not so good things’ are much more varied, and require individual assessment and problem-solving.
Most of the ‘good things’ about returning to work are things that make up the ‘importance’ dimension – things that people value.
Many of the ‘not so good things’ are about confidence to achieve those valued goals.

Motivation is therefore much less about lack of ‘importance’ of returning to work – in fact, for some people I would think that it’s precisely because work is so important that they are stuck. Why risk failure for something that is so important? Motivation in the case of people returning to work involves confidence that the individual can achieve within a workplace to the desired and required standard of performance.

What is all this commentary leading to?

  1. Pain assessments for people experiencing work disability simply must assess the social and cultural aspects of the workplace – both past workplace and present (especially if the person still has a job)
  2. Workplace assessments can’t just consider the physical, but also organisational, interpersonal and ‘cultural’
  3. When someone is having trouble returning to work at least one question should be asked: ‘do you think you will return to work?’
  4. When someone is having trouble returning to work, ‘motivation’ needs to be deconstructed: it’s more complex than simply the presence of secondary gain, laziness, lack of desire.  The importance and confidence an individual has for returning to work must be assessed, and the process of (often) building confidence initiated.

Pain may well be the cited reason for someone not being able to return to work – is it the real reason?  Disability from pain is a very complicated beast, pain intensity is not, by itself, the major factor.  When we start to look at it in more detail (which we will do tomorrow!), it could be any number of things.  If we fail to clearly identify the specific factors in any one individual, we run the risk of prolonged absence from work which is not desireable for anyone.  At the same time, what we know from motivational interviewing is the more we push against resistance the more defended that position will be.  Simply implying to someone that they are ‘not motivated’ will not achieve the desired goal if it is actually about confidence to manage the barriers around working.

Have a great day – sorry there are no specific references today, but I will make up for that very soon indeed!

In the meantime, you can’t really go past Chris Main and Chris Spanswick’s book ‘Chronic Pain: An Interdisciplinary Approach’ for a good description of the process of disability, incorporating the ‘blue and black’ flags.

Clear communication – an activity to encourage active listening


People who experience pain can have trouble saying what they want to happen – and difficulty hearing what other people really have to say. OK, I agree it’s a problem for us all – but

  • pain interferes with the capacity to attend to and process information, and
  • people with pain are often engaged in systems such as compensation or the health system
  • and communicating with their families (who are often also under strain)

so it’s good to help people learn to hear what is being said, and to be able to respond honestly and ‘assertively’.

Assertiveness is, however, a loaded word. I asked the group participants today what they immediately thought of when they heard the word ‘assertiveness’ and they said being bossy, dominant, pushy – and one person said it reminded her of hairy armpits!

So here are two activities that can be helpful so people develop skills for hearing and communicating.

The one minute silence

Pair off, sitting opposite each other.

If appropriate, hold the hands of the person and look into his/her eyes (this is best carried out with people in an intimate relationship – otherwise, simply looking into each others eyes is fine).

For one minute, one of the dyad can talk about anything he or she wants to. The other partner must listen without saying anything. After one minute, swap roles.

The paraphrase

As above (and following on from the above activity). The first person in the dyad talks for one minute about an issue that has been bothering them, while the second listens. After one minute, the person listening says ‘So you mean…’ and paraphrases the key issue. The first person can say ‘that’s it!’, ‘no, you haven’t got it’, or ‘nearly’, but gives no further information. The listener must continue with paraphrasing until the first person says ‘that’s it!’.

Then the pair swap roles.

Debriefing

  1. What was it like to be listened to? (first interaction)
  2. What was it like to really listen?
  3. What was it like when the person was trying to interpret/paraphrase what you said?
  4. What was it like to paraphrase what the person was trying to say?

I often then follow with the ‘DESC’ process to help with two things – (1) identifying what the ‘real’ issue is in a conflict (describing) and being clear about the emotional impact of that behaviour (expressing); and (2) then stating what exactly the person would like to have happen.

For those of you who haven’t encountered this process it’s as follows:

D= Describe the situation, being specific about one situation or event. e.g. ‘when I asked you about getting a dog, you walked out of the room’

E= Express your emotional response, keeping to ‘I’ messages. e.g. ‘I felt ignored and ‘cut off’.

S= State what you would like the other person to do, being specific about their action (but not about the outcome you want). e.g. ‘Could we meet to talk for 20 minutes this evening about the dog?’ (eg not presuming that the person will agree with your request to get a dog!)

C= Consequences – stating what consequences will be either for you or the other person. e.g. ‘And that way I can feel that we’ve been able to clear the air’ or ‘And that way I won’t keep on asking to talk about it again’.

This article by the London Pain Consultants outlines the rationale for effective communication, while this article discusses very briefly the place of assertiveness in developing confidence for self management.

For me, self management implies that the people we work with will be actively engaged in stating what they want to have happen with regard to their lives and health, and as a result they will be changing their behaviour, and doing things differently. This necessitates communicating these changes to other people, and doing this openly and honestly.

I find I carry out quite a lot of cognitive restructuring and challenging during sessions on communication skills – because it does seem that people are unwilling to ask others to do things differently, or to put up with them doing things differently, if they have not entirely convinced themselves of the benefits.

As a result, sessions on communication can often be quite intense CBT sessions – talking alone doesn’t do the trick, it must be accompanied by role play or practice!

I’m keen to hear what you think about communication, and whether (and how) you incorporate this into your pain management.  Drop me a line and let me know! And if you’ve enjoyed this post, don’t forget you can subscribe using RSS feed, and can bookmark my blog and visit regularly.  I’m posting roughly every day/every other day, so there’s plenty to read!

Ethics and therapy choices


I was having a discussion yesterday with a colleague who has recently started working in another area of health, away from pain management.  He was talking about the different philosophy that exists in this new area, and the change of practice that he was learning to deal with, and it made me stop to think about how our treatment practices are shaped by not only our ethics – the need to provide effective and appropriate treatment – but also our treatment model.

In pain management, we draw on the biopsychosocial model and our aim is to encourage people to maintain their wellbeing through their own efforts rather than using aids, appliances or even other people.  As a result, I rarely provide adaptive equipment, and although I encourage efficiency in biomechanics I don’t encourage ‘special’ gadgets or changes to the way things are done.  This is for a whole lot of reasons: to demedicalise the condition, to reduce the negative labelling of anything that smacks of ‘disability’, to encourage the person to be as normal as possible, to encourage independence rather than dependence – and because I so often see gadgets used for a short period of time, but then left… (I cannot recall how many so-called ‘ergonomic’ chairs, desks, keyboards and household appliances left out for the next inorganic collection!)

In my colleagues’ new environment, there is an expectation that if a person with a disability requests help to do something, lets say communicate using a computer, they will be provided with a piece of equipment.  The reasoning seems to be that if it can be provided to ‘improve access’, then it should.  And the ‘rights’ of the individual to have these gadgets is set in law.

And therein lies the rub.  Some of the requests for gadgets may in fact be disadvantaging the individual in the long term (although providing short term benefits), and at the same time there is a certain inequity about what access people with different types of disabilities have to gadgets, as well as compared with people without disabilities.

Here is a situation I have encountered personally: in a family there are two children, one with a disability that impairs handwriting (let’s call it dyslexia), and one without a disability.  The family can afford a single computer.  Because the person with the disability has the right to 24 hour access to communication, a laptop computer for his or her exclusive use can be obtained. This family has two computers now, one for the exclusive use of the child with the disability, the other to be shared with the rest of the family.

In the family next door, with two children, neither of whom have a disability, the parents cannot afford a laptop for each child and they have a single computer in the family.  The family have to share access to the computer.

Is this reasonable?

Here is another situation I have encountered: a person has a pain problem, and obtains under one set of legislation via an occupational therapist, a whole home office set-up including voice-activated computer software so she can dictate her work, ‘ergonomic’ chair that allows her to recline which she does in the afternoon, hydraulic-action monitor height adjustment so she can move her monitor appropriately when she reclines her chair, and special headset for the voice recognition software.  She is concurrently referred for pain management who encourage her to remain active, increase her level of activity, and ‘use it or lose it’.

Two therapists working with the same person, but providing completely different and opposing approaches to her ‘problem’.   Both thinking that their solution is ‘ethical’, but one solution that is entirely appropriate in the short term only, while the other aims to help in the long term.  The challenge is for both therapists to work with the same person without confusing her!  It is particularly difficult to help a person develop self management which often involves maintaining activity despite pain, when other therapies are aimed at minimising pain by minimising movement.

Of course both therapists are achieving the requested outcome – but at odds with each other!

How can this ‘systems’ failure be remedied?  The simple answer is to communicate – in the case of this person, the case manager referred the woman to both agencies without notifying either agency of the concurrent referrals.  It was quite by chance that the two agencies were sited on the same campus and found that the woman was attending each agency.

The ‘simple’ answer is not actually that simple really.  It does require a whole lot of effort to align both policy and practice so that the individual gets the best outcome in the short term without jeopardising the short.   It also means ensuring case managers learn something about the different models that apply to different disabilities.  And that requires a lot more education of case managers, those that develop policy, therapists – oh and the person with the disability.