Flexibility – of the psychological kind
More holiday reading to ponder… One of the fascinating developments in psychology over the past 50 years is the ongoing study into what constitutes psychological health. It’s been known by many names – ego-resilience, executive control and self-regulation – but the work on these areas hasn’t been pulled together into a coherent whole until recently. The authors of this paper suggest that this is partly because of the nature of defining this particular beast – what is health after all? Their argument, and one that I find rather appealing, is that a main feature of health is to be able to apply the right kind of response to the many different situations in which we find ourselves. In other words, flexibility.

Occupational therapists in particular will rejoice at the way in which psychological flexibility is defined in this paper, because it refers to “… a number of dynamic processes that unfold over time. This could be reflected by how a person: (1) adapts to fluctuating situational demands, (2) reconfigures mental resources, (3) shifts perspective, and (4) balances competing desires, needs, and life domains. Thus, rather than focusing on specific content (within a person), definitions of psychological flexibility have to incorporate repeated transactions between people and their environmental contexts.(emphasis mine).

Thinking about some of the people I’ve worked with (and reflecting on my own tendencies!), some of the problems that plague people arise from repeatedly trying to apply one set of coping strategies to a new or challenging situation.  When someone experiences a limitation in an area of function, our problem-solving minds typically want to ‘fix’ it – and while this can give us some great work-arounds it can also lead us up the garden path when those solutions don’t apply.

Let me illustrate: many of us grew up with the maxim ‘if a job is worth doing, it’s worth doing well’, or ‘don’t leave a job half-done’.  This is a great rule of thumb in most situations – it stops us from being half-hearted and it keeps us committed.  There is good reason for it being one of those things our parents and teachers drum into us.  BUT when it’s applied to managing chronic pain it can work against people – because it invites people to persist in completing activities in a ‘boom and bust’ pattern.

While most people can readily apply ‘exceptions’ to rules like ‘if a job is worth doing, it’s worth doing well’ so that if the person has a bout of influenza, or has just had an earthquake (for a very real example to us Cantabrians!), for people with chronic pain it can be hard to work out when to recalibrate expectations.  This is a very real example of the need to be flexible about expectations and behaviours.

While it’s easy to see the need to be flexible in terms of choices around temporary changes to health status or environmental demands, it’s much more difficult for many people to see the need to review choices in light of longer term changes to health status.  As a result, so many people I’ve worked with end up applying a rigid, global ‘rule’ to the way in which they live their lives, despite longstanding reductions in their functioning.  This leads to increased distress as their internal expectations don’t match what they can actually do – and a process of managing emotions while working to be more flexible with internal rules is a major part of the work of pain management.

It’s also one reason I don’t think it’s possible to work in pain management without a working knowledge of how to help people identify their thoughts and the effect of thoughts on emotions and behaviour.  After all, it’s relatively easy to ‘teach a skill’ like activity management – but a whole different ball game to help the person feel OK about applying activity management in his or her own context.

Kashdan and Rottenberg identify that there are several underlying building blocks of psychological flexibility.  These include: executive functioning – those parts of the brain involved with prioritising and integrating cognitive capabilities such as being able to shift attention away from what is less important to what is important; self-regulation – being able to tolerate distress and experience it but make choices about responding; being able to selectively apply task persistence or to choose to stop; identifying emotions and recognising their temporality.  As Kashdan and Rottenberg state: “Creating categories and labels is normal and it is only when it is automatic such that a person is unable to detach from particular thoughts and feelings, where they are viewed as objective representations of reality instead of temporary, products of the mind.” It’s that swift and automatic labelling that allows people to notice but not react, and is a skill we start to learn from childhood.

They go on to say “When a person is unable to accept frustration and unwanted negative experiences, attentional  capacity and decisionmaking capabilities are narrowed…Instead of flexibly responding to a situation in an active  manner, a person preoccupied with avoiding experiences is psychologically unavailable to adapt to the cues afforded by an existing situation.”

Finally, they identify “executive functioning also typically includes working memory and recall, information processing speed, and the ability to inhibit behavior.” Persisting memories can interfere with making accurate assessments of here and now, being able to rapidly recall information enables people to draw on appropriate knowledge for a specific situation and evaluate its usefulness, and being able to stop behaviour that is unhelpful is a really important aspect of developing an adaptive response to a new situation.

An ongoing job for any human is to “… maintain a delicate balance between investing effort into our current  surroundings and conserving mental energy for potentially significant future situations.” We typically simplify this by developing habits and routines (sound familiar Kielhofner fans?).  Part of psychological flexibility is being able to ensure these habits and routines support flexibility rather than remain fixed and not necessarily helpful.

I think the construct of psychological flexibility, and particularly acknowledging the ways in which executive functioning is such an important feature, is something clinicians working in chronic pain need to come to grips with.  If we can help people develop flexible and adaptive responses to the limitations of chronic pain, while recognising that chronic pain directly fatigues executive functioning, we’ll be going a long way towards helping people re-engage with what is valued and rewarding in their lives.  More learning for us clinicians, methinks!

Kashdan, T., & Rottenberg, J. (2010). Psychological flexibility as a fundamental aspect of health Clinical Psychology Review, 30 (7), 865-878 DOI: 10.1016/j.cpr.2010.03.001

What do people with chronic pain & health anxiety worry about?
While there is a whole heap of research going on in the area of chronic pain, something that seems to be missing at times is the experience of the person who has the pain. When I take a look through a journal I can see loads of articles with fabulous treatments and awesome brain scan findings – but in the end, pain is and always has been, a private, personal, subjective experience that has individual meaning and impact. Today I’m looking further into this phenomenon called health anxiety in people with chronic pain, and discussing the themes that a group of researchers based at King’s College London found when they talked to people with chronic pain with both high health anxiety and low health anxiety.

It’s thought that the prevalence of high health anxiety in people attending a tertiary pain management centre is roughly 50%.  Health anxiety is about  ‘preoccupation with a belief in, or fear of, having a serious illness’ (Salkovskis & Warwick, 1986; Warwick & Salkovskis, 1990).  It’s not just found in people without any health problems (ie a mental health problem), it’s also found in many people who have a diagnosed health condition, and it is a particular problem in chronic pain because so often it’s impossible to ‘locate the cause’.  This means the usual reassurance (as I wrote about yesterday) doesn’t have much effect, and the person with the health anxiety can become incredibly distressed.  Distress and health anxiety can lead to zealous pursuit of investigations and treatments and create havoc for the person and his or her treatment providers.

The cognitive behavioural model of health anxiety states that people with this problem tend to have a long-standing bias towards misinterpreting or overinterpreting bodily symptoms or health-related information as evidence that they have a serious health disorder (or are at great risk for developing something serious).  As a result, they can demonstrate unhelpful responses in the domains of cognition (e.g. selective and enhanced attention to information perceived as illness related); affect (e.g. anxiety, depression, anger); physiological (e.g. increased bodily arousal); and behaviourl (e.g. increased bodily checking, reassurance-seeking, avoidance, and other safety-seeking behaviours).

This study by Tang and colleagues took a group of 60 patients with chronic pain attending a pain management centre, half of whom had high health anxiety and half with low health anxiety.  They conducted in-depth semi-structured interviews with these patients, and looked at how much the cognitive, affective, physiological and behavioural responses described by the participants were consistent with the predictions of the health anxiety model.

The groups were distinguished in terms of health anxiety by their responses on the Short Health Anxiety Inventory, a popular tool for assessing clinically significant health anxiety.  The high health anxiety group all scored well above 18, the cut-off score for Health Anxiety, while the low health anxious group didn’t reach this cut-off at all.

The interviews were then carried out by a clinician who was not aware of their health anxiety status, and the interviews covered topics based on the health anxiety model – things like appraisal of pain, cognitive, affective, physiological and behavioural responses to an episode of intense pain, and their own experience of pain and looking for treatment.

Five themes were identified from these interviews, and there were some distinct differences between the people with high health anxiety and those with low health anxiety.

Appraisal of pain – high health anxious people described it as ‘horrible’ and meaning that something is wrong and it’s a sign of worse to come.  Low health anxious people described it as hurting, but nothing sinister is going to happen.

Preoccupation with pain – high health anxious people indicated that pain cannot be ignored while people with low health anxiety said things like ‘there’s not much point in thinking about the pain’

Coping strategies (sleep) – people with high health anxiety had a lot of trouble with sleep, but at the same time it was a source of escape, while none of the people with low health anxiety mentioned sleep in this way.

Coping strategies (engagement in activities) – high health anxiety people make a lot of alterations to the way they do things to avoid adding to the pain, while people with low health anxiety carry on with what needs to be done.

Self-identity – people with high health anxiety described themselves as being ‘taken over’ by the pain, while those with low health anxiety indicated that pain is part of them, but doesn’t define them.

Suicidal ideation – people with high health anxiety said things like living with pain is a punishment and not worth living, while people with low health anxiety didn’t discuss this at all.

Tang and colleagues believe that these findings support the cognitive behavioural model of health anxiety in chronic pain.  Along with the themes I’ve described here, Tang et al also describe how behaviours associated with these themes would serve to maintain and potentially exacerbate distress, avoidance, rumination and reassurance seeking.  And we know from the study I discussed yesterday, that patients who are highly distressed often receive more information about physical aspects of their problem, often have more investigations, and procedures rather than receiving empathic and psychosocially supportive input from their treatment providers.

I know that the Centre in which I work doesn’t routinely assess health anxiety.  I wonder whether it could help us identify those people who really need less biomedical input, particularly more investigations, and help us to guide their GP’s and other health providers to provide them with more emotional support. While we can certainly use the cognitive behavioural model of health anxiety in our treatments, it seems from the work of Salkovskis and others that there is a underlying processing bias towards interpreting body symptoms in a more fearful way that may not be able to be completely abolished.  Maybe for this group of people we need to help their health care providers to give them consistent emotional and psychosocial support for every health problem they see their treatment providers for, along with, of course, best practice help for the health conditions they have.

I’ve posted before about strategies to help people with high health anxiety cope with their problem, using the cognitive behavioural model promulgated in this paper – take a look here – and it does look as though this is helpful.  One question: why is it not integrated into usual clinical practice?

Tang, N., Salkovskis, P., Hodges, A., Soong, E., Hanna, M., & Hester, J. (2009). Chronic pain syndrome associated with health anxiety: A qualitative thematic comparison between pain patients with high and low health anxiety British Journal of Clinical Psychology, 48 (1), 1-20 DOI: 10.1348/014466508X336167

Does thinking keep it so? Health anxiety & memories
Years ago, the relationship between depression and chronic pain was the hot topic, and it’s only more recently that anxiety and pain have become popular. So slightly tangentially, but I think you’ll see how it relates, today I want to muse a bit about health anxiety and some of the findings from this interesting area of health management, and how it might transfer into pain management.

One of the things a person with chronic pain often fears is being thought of as a hypochondriac. Somehow ‘That Word’ has a load of really negative connotations that suggest the person is simply making more of their problem than necessary and really ‘should’ pull themselves together, build a bridge, and get over it. Hypochondriasis is better-named ‘health anxiety’ and the underlying thinking processes associated with it are very similar to those underpinning the anxiety disorders – things like checking (OCD), reassurance-seeking (separation anxiety), avoidance (phobia) for example are very much part of health anxiety. People with health anxiety seek health care input often, and can remain dissatisfied and unreassured as well as using more health care – and in this paper by Muse, McManus, Hackman, Williams and Williams, is thought to occur in about 5% of the population. While the actual figures on the prevalence of health anxiety in people with chronic pain don’t seem to be readily obtained, it’s no surprise to me to think that some of the people with high health use associated with chronic pain could also have health anxiety.

One of the things that is known to maintain PTSD is flashbacks or visual imagery of events,  situations or items similar to the triggering event, and in this paper the authors tried to identify whether people with health anxiety also experience intrusive imagery – which may also serve to maintain the anxiety disorder.

Basically, they interviewed 55 patients, asking them to focus on their experiences of being anxious about their health in order to identify related intrusive imagery.  Participants were then asked to describe their most distressing image and then answer questions relating to this image.  These responses were analysed using content analysis to identify themes, and to identify the frequency of imagery and the intrusiveness.

Participants were then asked to focus on their image, and identify whether it was a memory, and if so, how distorted their memory was (although I think this is a pretty difficult challenge!).  Finally they were asked to rate five behavioural responses to that image, the responses being those associated with health anxiety such as avoidance, checking, seeking reassurance and so on.

What they found was a large percentage of the participants clearly recalled instrusive images (43 from 55), and there were no differences in terms of gender, or socioeconomic status, nor even symptom severity between those that did, and those that didn’t.

On average, the 78% of participants who did describe intrusive imagery experienced this about 3 – 4 times a week, images were vivid and distressing, and the majority of participants felt as if they were ‘right there’ – or looking out through their own eyes at the event, with more of them seeing this as an event occurring in the future.

What did they see?  Four main themes were identified – i) being told ‘the bad news’ that you have a serious/life-threatening illness (6.9%), ii) suffering from a serious or life-threatening illness (34.5%), iii) death and dying due to illness (22.4%) and iv) impact of own death or serious illness on loved ones (36.2%).

72% of those describing intrusive images also said their imagery was associated with a memory – either of an actual event occurring to themselves, or an event occurring to someone else but with the person being the one affected rather than being an onlooker.

It looks very much like memories of serious ill health, or of someone else being seriously unwell, can become a source of negative imagery that then can become a maintaining feature of health anxiety.  By engaging in the typical anxiety-maintaining behaviours of checking, reassurance-seeking, avoidance, distraction and rumination both the images and the anxiety about health continue.  It’s worth remembering that the images were projecting forward in time – and probably helping to increase the belief in the probability of the event actually occurring.

What might this mean for people with chronic pain?

When I recall the number of people who develop chronic pain after a traumatic initiating event like a motor vehicle crash, or a sudden work accident, and when I think of some of the ways in which the news can be conveyed to people: ‘I’m sorry you will need surgery’, ‘there’s nothing I can offer you’, ‘you’ll have to take these medications for the rest of your life’, or ‘I don’t really know what’s wrong with you’ – I can quite easily accept that for some people this could trigger health anxiety, but a specific health anxiety related to their pain problem.

It helps to explain, at least to me, some of the reasons people carry on looking for more tests, more investigations despite nothing significant being found, and need more reassurance that somehow doesn’t actually reassure.

This paper also makes me wonder whether it’s worthwhile exploring the events surrounding the initial onset of pain, and just as importantly, the things the person has learned from his or her interactions with health care providers.  It might also be useful to explore how members of the person’s family have heard about their health status – has anyone else in the family and friends had a serious illness, or been advised they have an ongoing pain problem.

Once again I’m struck by the need to go beyond the individual and his or her immediate problem, and take the time to explore the context in which the problem developed – especially the other people and events that have occurred in the person’s life.

A lot more work needs to happen for this idea of health anxiety imagery and chronic pain anxiety to be scientifically established as a robust phenomenon.  But it’s an intriguing possibility because treatment of health anxiety, while challenging, is reasonably well-etablished.  It might give some guidance to GP’s and other primary health care providers as to what NOT to do for people who are anxious about their pain.  Don’t ‘reassure’ because it’s not that reassuring, don’t go ahead with more investigations ‘because it might reassure the person that nothing’s wrong’.  The process of checking and re-checking seems to increase the anxiety and maintain it.

Next post? What to do instead of reassuring!

Muse, K., McManus, F., Hackmann, A., Williams, M., & Williams, M. (2010). Intrusive imagery in severe health anxiety: Prevalence, nature and links with memories and maintenance cycles Behaviour Research and Therapy, 48 (8), 792-798 DOI: 10.1016/j.brat.2010.05.008

Top down, bottom up or both? Attention to pain
I guess we all pretty much know that our brains don’t seem to capture everything that goes on around us – thankfully we can filter out a lot of unnecessary information (no, I don’t want to know what that funny noise outside is right now!) so that we can focus on what is important. When it comes to pain, the limited capacity of our brains to process information has been used to explain why there are times that, despite a large amount of nociceptive input, we can remain pretty much oblivious to it. Clearly it would be wonderful if we could harness this and use it as a form of analgesia.

The place to start, I guess, is with recognition that one function of our brain is to keep us focused on important goal-directed activity. Because of this function, some information that is available both from inside the body and from outside, needs to be prioritised. ‘Top down’ processing models suggest that our brains have a process of intentionally choosing information that is relevant for whatever goals we are aiming for. In this model, the sensitivity of neural responses is modulated up or down, depending on the goal, and it’s been postulated that prefrontal and parietal areas are likely to influence these mechanisms.

‘Bottom up’ models suggest that there is a process of unintentional ‘capture’ of attention by the stimulus itself – if a fire alarm goes off without warning, we’ll usually be alerted to it without having to stop and think too hard! The term used to describe the characteristic of this ‘alerting’ feature is ‘salience’, or the degree to which that specific stimulus contrasts with surrounding stimuli. For something to be salient, it needs to be novel or new, not often present, or directly relevant to our goals perhaps from previous experience.  It’s thought that ‘pre-attentional’ systems are involved in detecting salient or novel stimuli – two separate systems have been found for the auditory system for example.  These ‘bottom up’ systems can act as a distraction from ‘top down’ goals because the attention can be switched to unimportant features of the environment or body and reduce performance.

It’s thought that ‘bottom up’ attention, while unintentional, is influenced by ‘top down’ processes because the top down processes establish the amount of attention focused on a task (attentional load), so that when load is high, irrelevant information is not processed as much.  Top down processes also establish the ‘attentional set’ or the type of information that is prioritised as being relevant to the goal – if a stimulus that is irrelevant matches one aspect of these features, it’s likely to capture attention.

Pain is known to capture attention ‘bottom up’ when its new or novel, intense, or is threatening.  This means that vague and commonplace pains like epigastric pain, can often be ignored.  Because most of us will have had heartburn, and know that it usually passes without too much of a problem, we don’t usually pay too much attention to it.  The situation would change, however, if we’ve had an MI – because that pain now represents another whole new threat.

The parts of the brain known to be associated with attentional capture by pain are the brain areas underlying the P2 responses of laser-evoked potentials.  The midcingulate cortex (MCC) is one of the main generators of this P2 signal, and it’s known that this part of the brain is associated with novelty detection, directing attention toward a specific stimulus, and where our behaviour needs to be regulated.  The MCC can be seen as a part of the brain that is needed to coordinate a speedy motor response because of its close relationship with premotor areas.

Enough about bottom up attention – what about top down?

Well, there are many studies showing that bottom up attention to nociception can be influenced – the amplitude of P2 potentials is decreased when people are engaged in demanding activities, responses in the MCC, paracentral and operculo-insular areas are decreased when people are doing absorbing tasks, and responses in the primary and secondary somatosensory cortices are influenced by how demanding the task is (attentional load) all supporting the idea that top down attention affects nociceptive processing by biases somatosensory brain activity.  This is why, when we’re engaged in an activity that is interesting and requires a bit of brain effort, our perception of pain is reduced.

Unfortunately, top down attention can also direct us towards painful events – especially when the nociceptive stimulus is being delivered to a part of the body that is also engaged in an activity (similar attentional set), and can be influential in individuals who expect or catastrophise about pain, where it has been shown that there is greater activity in operculo-insular and MCC areas.  It can work both ways.

Prefrontal and parietal areas are known to be involved with top down attention to or from nocicpetive and nonnociceptive stimuli.  Exactly what their job is is unclear, but some experiments suggest that the dorsolateral prefrontal cortex is important for maintaining priorities relevant to goals, by increasing the involvement of executive functions to the job of processing relevant information, thus avoiding the interference from irrelevant stimuli.  Maybe the dorsolateral prefrontal cortex (DLPFC) and the intraparietal sulcus(IPS)  are able to maintain both attentional load and attentional set, to make sure we’re able to focus on the goal we had in mind, rather than being distracted by pain.

So what does this mean for us?

Well, the authors of the paper I’ve been paraphrasing, suggest that the bottom up factors act as a signal to salient events, and this influences the operculo-insular areas, and by the MCC – this triggers attentional bias towards nociceptive input.  Both attentional load and attentional set seem to modulate how much these salient events disrupt our attention away from the task in hand.  Remember that attentional load is the cognitive  ‘grab’ of whatever we are focusing on, so it also allocates resources or effort to maintain that focus.  The DLPFC  keeps this focus by directing executive functions to the most important task.  Attentional set guides that ‘what is important’ or matching qualities that the person is attending to in order to achieve the goal, and all stimuli that meet at least one of those qualities will capture attention.  This is thought to be associated with activity of the IPS which detects similarities of various stimuli and focuses toward or away from responses to features in the environment.  So there is a sort of balance or dynamic between the bottom up and top down influences on attention.

This model is pretty important – most experiments in pain have been with acute pain in controlled settings where there is some degree of expectation that something will happen.  This is not a lot like real life where pain is often unexpected and happens in a busy and demanding context.  For people with chronic pain, it’s already been found that cognitive deficits occur and while there could be some truth in the current explanation of ‘anxiety’ or ‘hypervigilance to pain’, the neurological explanation may well be more along the lines of this top down and bottom up allocation of resource.  It’s especially useful to consider this model when looking at executive functions and how these, and self regulation, can be impaired in people with chronic pain – maybe it’s because it’s more difficult for people with chronic pain to exert down-regulation or to switch attention from one thing to another – or even to inhibit irrelevant signals in order to focus on important aspects.

The authors also suggest that attention management may become a more important part of a cognitive behavioural approach than it has in the past – mindfulness occurs to me as a particularly useful way to develop effective executive control.

Legrain V, Damme SV, Eccleston C, Davis KD, Seminowicz DA, & Crombez G (2009). A neurocognitive model of attention to pain: behavioral and neuroimaging evidence. Pain, 144 (3), 230-2 PMID: 19376654

Measuring the total impact of a health condition
When I think of the ‘cost’ of having a disability, I have to say I usually think about the effect of the disorder alone on the ability to do valued activities – I haven’t usually thought about the impact of the treatment itself on how people live their lives. I came across this paper by Gerald Devins while searching for ways to measure the effectiveness of interventions on the lives of people attending the Pain Management Centre in which I work.  (I had been looking for something that could measure ‘interference’ of pain on activity and found a couple of good measures such as the Interference subscale from the Westhaven Yale Multidimensional Pain Inventory and the Interference bank of statements from the PROMIS bank.)

Anyway, Devins introduced me to the concept of  ‘illness intrusiveness’ as an underlying construct that identifies both the illness-related limitations AND the treatment-related impact on the ability to engage in activities that are important – and these activities include those that are not directly related to the disease impact itself such as normally rewarding opportunities (like travelling overseas being limited by sitting tolerance, for example).  In other words, this model looks at the effect of illness on the disruption of lifestyles, activity and interests – and considers that illness intrusiveness is a ‘fundamental determinant of the psychosocial impact of chronic disabling and life-threatening disease.’ (p 592).

There are a couple of reasons this model struck a chord in me – the first was the reference to valued activities. Illness intrusiveness is thought to interfere with psychological wellbeing by reducing the availability of the usual positive effects of engaging in valued activities (ie it does take more effort to get involved in enjoyable activities when you have pain – even though the activities are fun!) and it also reduces personal control by reducing the ways to obtain positive outcomes and/or reducing the ability to avoid negative ones. In other words choices are restricted.

It also appeals to me because it starts to include not only the disease effects, but also the impact of treatment on how well people feel. I don’t think the effects of treatment are always appreciated – such as the time needed for appointments; the side effects; the social effects of feeling like a ‘patient’; the ups and downs of hope and disappointment as treatments are tried and often fail (especially in chronic pain) – even the stigma of being seen by a psychologist or needing to take antidepressant medication (although I don’t see it as a stigma!).  All of these things really affect the sense of how much a health problem ‘gets in the way of’ life.

Devin’s work, along with others, has explored various factors that interact to influence both illness intrusiveness and subjective wellbeing. 

From the diagram you can see how this model integrates contextual factors and social/psychological factors (yay!) that can either exacerbate or mitigate the effects of a disease/disorder on the individual.  It’s wonderful to see how these factors have been included because it brings home yet again how the biopsychosocial model MUST include the social as well as the psychological and biophysical.  *steps off hobby horse quickly*

As well as introducing me to this construct, Devins’ paper also discusses the pretty extensive support for it across a range of disorders and populations.  From my understanding, it seems that, as we’d expect

  • the more severe the disease, the more intrusive it is
  • side effects and treatment schedules are associated with more intrusion
  • reducing the disease by various means is associated with reduced intrusion
  • the intrusiveness of a disease is associated with a sense of less personal control
  • illness intrusiveness also correlates with other, more commonly measured outcomes such as mood, quality of life and so on – and it’s not equivalent to the impact of the disease or treatment alone
  • about eight factors that influence psychosocial impact of a disorder don’t themselves directly influence illness intrusiveness – for example, stigma, self concept, age, stage in the family life cycle, role importance, culture and the context of events in whcih disease and treatment occur (need to explore that one more to understand it)

Devins has developed a 13-item scale to measure, through self-report, the intrusiveness of a disorder.  It’s been used in 36 different disease groups and with thousands of indviduals (although each disease group varies in number from 42 to 2300).  The scale itself has been found to form three subscales – relationships & personal development, intimacy and instrumental.

The paper I’ve referred to discussed psychometric properties of this scale, and it seems to have very good internal reliability and test-retest reliability (.80-.90 alpha coefficient for internal consistency) and test-retest coefficients of .80 and .90. over 9 months, 18 months and one three month test for end stage renal disease.  Construct validity, always a tricky one to measure, has been established via converging findings in all the various factors across various conditions including both medical and mental health.  The paper also discusses other measures of validity such as discriminant validity, criterion-related validity and so on.  It’s always an ongoing process to determine the validity of an abstract construct, so this work will continue.

In terms of the factor structure (ie the three subscales) this has been demonstrated across eight disorders including one for psychiatric outpatients with anxiety disorders, and this also seems to remain over different languages.

So, here we have a measure that seems to measure something quite different from other questionnaires; it’s reliable and validity is promising; it provides consistent subscales – but it’s not easily interpreted at present.  Hence one of my reasons for discussing it –  Devins readily acknowledges that this measure requires some really sound normative data with large groups or smaller ‘local’ norms.  There isn’t a specific standard cut-off for ‘mild’, ‘moderate’, or ‘severe’ intrusion and this will be needed before it is useful clinically, although it has been used to compare the effectiveness of different treatments, for example.  Devins also acknowledges that as our cultures have widely divergent ideals about what a ‘good life’ looks like, testing this measure in different cultures and subcultures will be important – for example, in a rural farming area of New Zealand, the intrusiveness of a chronic pain problem could be more intrusive than the same problem in an office worker in an city centre in Australia.

A couple of points I want to make here:

  1. It’s exciting to come across a new concept to describe how people cope with illhealth – and particularly one that considers more than the individual in isolation
  2. This assessment measure has already had a good deal of research carried out on it, across many of the health disorders that affect quality of life, and its been translated into different languages
  3. The psychometric properties are pretty good – it seems reliable, and validity is being established, it also seems to be sensitive to change and measure something quite unique from other measures
  4. It still needs more work to give us usable information relevant to individuals in New Zealand – it shows some of the complexity involved in developing new measures, and when considering social and contextual factors
  5. BUT it might be worth considering as part of an outcome measure for pain management programmes and when informing policy makers of the real impact of alternative treatments

BTW the paper actually provides the items of the scale.  They include health, diet, work, active recreation (sports), passive recreation (reading, music), financial situation, realtionship with your spouse, sex life, family relations, other social relations, self-expression/self-improvement, religious expression and community/civic involvement.

Devins, G. (2010). Using the Illness Intrusiveness Ratings Scale to understand health-related quality of life in chronic disease Journal of Psychosomatic Research, 68 (6), 591-602 DOI: 10.1016/j.jpsychores.2009.05.006

What goes in to the “social” part of biopsychosocial?

The biopsychosocial model gets bandied about a lot in pain management – but often it’s recognised as ‘bio’ and ‘psychosocial’, as if the social part doesn’t really exist outside of the psychological.  I have to say at the outset I’m not a sociologist but it does seem to me that to conflate psychological and social could very well miss some important aspects of the model, and that this might not be the best for the people we work with. 

Over the past couple of weeks I have been reading more about the social aspects and while I’m not yet entirely certain of all the elements that could be encompassed by it, I’m starting to get a feel for at least some of them.

The first observation I have is that often the biopsychosocial model gets broken down into ‘biophysical’ then ‘psychological’ with ‘social’ being a bit of a poor cousin.  I don’t think this is what Engel intended, certainly as I read Engel’s papers, I find many references to the value of the biophysical aspects – “as a scientific framework within which to elaborate the disordered bodily mechanisms involved in disease the biomedical model has been extraordinarily fruitful” (Engel, 1976).  But Engel was extremely clear that this model has limitations and, as we know, when using any model, it constrains the way we think about and identify problems

Engel cited a large study ofthe type of patients that family physicians saw in which only 7% had “problems with psychologic and social origins and psychologic or social manifestations,” but found that when these cases were reviewed, they included “only depression, marital problems and anxiety neurosis, hardly even representative of psychiatric morbidity”.

Engels view of the ‘other’ parts of the biopsychosocial reflect his concern that when patients complaints about doctors and health system were really listened to, the areas they thought weren’t addressed well were “that doctors don’t communicate well, that they don’t really listen, that they seem insensitive to personal needs and individual differences, that they neglect the person in the zeal to pursue diagnostic and treatment procedures.” How much has changed? 

He goes on to say “they stress the unavailability of the physician and health services, often as much indicative of psychological remoteness as of economic barriers or geographical distances”. I’d suggest both economic barriers and geographical distances are social aspects that continue to make accessing health care really difficult for some.

So far, while looking through Medline and PsychInfo, I’ve had trouble identifying articles that are specifically ‘social’ in orientation.  In my own mind, ‘social’ equates to the following:

  • interpersonal communications
  • pain behaviours (facial expressions, guarding, rubbing the area, spoken words)
  • roles in life – friend, partner, child, parent, worker etc
  • family of origin relationships
  • extended family relationships
  • community networks
  • socio-economic factors
  • interactions with the physical environment including access to buildings and transport
  • cultural aspects – across multiple cultures, not simply ethnicity
  • legislative policy and practices for healthcare delivery
  • legislative policy and practices for sickness and support for being unwell

And obviously many more – but it’s less common to find discussion of these factors by comparison with those that discuss biophysical and psychological aspects.

Engel makes a lovely point in his 1976 paper.  He suggests that the biomedical model thinks in a linear ’cause’ – leads to ‘effect’, and if the ’cause’ is cured, the ‘effect’ has gone and the person returns to normal.  I’ve been told by one doctor that ‘once the pain has been abolished, the person is back to normal and there is no need to consider psychosocial factors’. Needless to say, I beg to disagree!  Engel’s suggestion is that the biopsychosocial model is a systems model that involves ongoing interactions between all three aspects, and that, in his words,

“every change becomes part of the history of each system, rendering it different at every successive point in time… there can be no return to status quo ante. Health restored is not the former state of health but represents a different intersystemic harmony than existed before the illness, with characteristics based on all the system changes incurred during the illness. By virtue of the illness not only is the individual changed as a person, but so too may be changed others in relationship to him, in the family as well as the community.” (emphasis mine)

Every event has some flow-on effect for the person involved.  Even if the tissues heal – the person processes and develops an understanding about ‘what happens when’, and this understanding is shaped not only by the effects on the tissues, but also on the responses and expectations of the greater system within which the person lives.  Contextual factors always have an effect – we simply can’t see people as ‘the back pain’ or ‘the CRPS’, treat only that part and think we haven’t had some effect on the person-in-context.

What does this mean for me?

Well the first thing is that when I ask about the history of both the onset of the pain problem and the treatments the person has had, I’m not simply cataloguing events in some sort of timeline.  I’m looking to see how the person interprets these events, and what meaning they have made from it.  After all, something occurred for the person to look for treatment in the first place – and it’s not simply the pain, it’s what the pain means to them.  At each successive interaction, the person will interpret it in some way.  This makes our encounters incredibly potent, even when we think we’re ‘not doing anything’.

Each health care interaction is a social exchange. That means the health provider and the person are within a social context, there are rules (or folkways and mores) that influence behaviour and also influence what is discussed and what is not.  The person going to see a health care provider lives in a community, has people around him or her – even if they’re not directly living with or interacting with those social factors – they’re geographically situated near or far from health care, they’re in an economy that places value on certain activities and roles, they’re in a community and culture that shapes the way they view what is healthy and what is not.

I think that means I need to learn a whole lot more about social and cultural and political aspects of health than I ever thought necessary, for to ignore them is to be blind to some of the most powerful influences on individual health.  You can bet I’ll be writing more about my explorations!

Engel, G. (1979). The biopsychosocial model and the education of health professionals General Hospital Psychiatry, 1 (2), 156-165 DOI: 10.1016/0163-8343(79)90062-8

How to judge a treatment
Last week I discussed an interview with F Sommer Anderson and also discussed aspects of central sensitisation syndromes, and Will Baum from where the client is kindly forwarded me a response by Dr Anderson.  I am going to muse on one or two aspects of her response because they raise issues that I think are relevant to anyone working in health – and more importantly, anyone working in pain management.

For Dr Anderson’s website, go here, and for a copy of Dr Anderson’s response to my post, click here (when I learn how to link word docs!)

Pain, like many other conditions, is complicated by the fact that it’s invisible – we don’t have any objective measures of pain itself, and we have to rely on behaviours (including verbal self report and movements) to determine whether treatment has done any good.  Behaviours are strongly influenced by external factors such as other people’s responses, along with internal factors such as beliefs and expectations. 

We therefore have a ‘proxy’ for the experience of pain that doesn’t correlate all that well with anything else – not even tissue damage, nociception, or disability. Pain behaviour does, however, have relationship with psychological distress and consequently, when distress is reduced, pain behaviours often also reduce.

What this means for anyone working in the field of pain management (or pain reduction) is that it’s difficult to establish whether what we’re doing is changing the pain experience itself, or simply the behaviours around having pain such as how much the person will report their pain.  And it means we have to rely on what the person DOES as a proxy for working out whether our treatment has worked.

I’ve made it very clear that I’m in the business of helping people live well despite having pain, I don’t aim to change the pain intensity much (although sometimes that does happen).  This is because the research seems to show that it’s not inevitably the pain intensity that leads to distress and disability, it’s the beliefs and attitudes and the way in which pain interferes with living life that contributes to difficulties.  Distress associated with pain leads to more searching for treatments, which often temporarily reduce this negative emotion, but distress can increase once the initial response to treatment settles down.  We see this time and again in pain management programmes.

How do we work out what is a good treatment?  Do we look at how many people have attended for this particular type of treatment?  Do we look at how many people return for the same treatment?  Do we judge a treatment by how many people say they’re happy with their treatment? Do we judge it by how many books have been sold by the author or originator of a treatment?

All of these things are basically a popularity vote.  How personable, charismatic, or even solicitous the treatment provider was; how the treatment was conveyed to the person; how much advertising was carried out; how well-written the books were; how many people studied under the originator of a treatment – all of these can influence how often a treatment is tried.

If you’ve picked nothing else up from my blog posts, you should have seen a bias toward evidence-informed practice.  What I mean by this is that I draw from the empirical peer-reviewed literature (with all the publication bias and other faults that it has) to inform my clinical practice.  I do this because, although there are faults with published studies, many more of the usual biases that afflict anecdotes and case studies are minimised.

There are loads of criticisms of  ‘evidence-based practice’ – the main one being that innovation and novel therapies can’t be introduced until the ‘gold standard’ randomised controlled trials have been carried out.  The rigour of having to conduct one of these RCT’s means that often the inclusion and exclusion criteria (as well as the treatment itself), and the outcomes achieved, can differ from what we might see in everyday practice.

Another criticism of evidence-based practice is that studies are carried out on groups of people, and results analysed in terms of groups of people – whereas we see individuals, one at a time, all with their unique presentation.  How, it is argued, could a ‘generic’ treatment be relevant to the unique person I am seeing?

I’m not a very technical person when it comes to arguing this, but here’s my take on judging treatments.

  1. Each individual I see has a unique presentation, and my ‘working hypotheses’ for why they have presented this way at this time, are just that: hypotheses that need to be tested for this person in his or her situation
  2. The good thing about science is that all hypotheses are testable – if they can’t be tested, then it’s not really science, it’s faith or belief
  3. Over time, evidence accumulates, giving more or less support to any particular hypothesis
  4. Hypotheses are drawn from theories – and theories are judged on how well they explain what we see in the real world, with the least number of special assumptions, and the ability to explain the most
  5. Theories are modified as more evidence from testing various hypotheses is gathered – this is why there are often so many conflicting views in the media about what risk we face from eating chocolate, drinking wine, enjoying the sun or exercising
  6. Over time we should see an accumulation of evidence to support a theory – or not.  And we certainly see this with respect to the view that ‘humours’ cause disease, ‘bloodletting’ cures anything – and (dare I be contentious?) homeopathy d0es nothing.

Why do I raise this when thinking about Dr Sarno’s theory?  Well, it relies on some untestable hypotheses, it was developed many years ago but hasn’t been subjected to RCT’s, and instead of scientific evidence for it ‘working’, it draws on numerous case studies, anecdotes and books being sold as evidence.  This isn’t my way of practising.

I’ve included this paper on patient autonomy for managing chronic conditions, because it illustrates the dilemma ‘consumers’ and health providers face when they look for treatment.  While I really support patient autonomy (after all, I AM a patient – aren’t you? at least sometimes?), at the same time I want to provide something that I know is effective on the basis of systematically controlled studies.  If a person comes to me wanting rolfing, deep tissue massage, crystals, or ‘healing the inner child’ as a way to help them manage their persistent pain, I can’t, in all honesty, go ahead and do it (or send them off to find someone else to do it).  I believe I have an ethical responsibility to let them know the state of play in the peer-reviewed, scientific literature.  I also have to make a judgement about the health literacy of the individual I’m seeing.  How much do they weigh up the various options, how much do they know, what about the ‘power’ relationship between me and them – and even how I phrase the various options can all influence whether someone will choose to adopt a treatment or not.

This doesn’t make me all that popular at times – either with patients who really want something that they feel comfortable with, or with providers who like to provide a certain treatment irrespective of the status of the scientific literature.  But it is about honesty, truthfulness and using a systematic process to discover what has the greatest probability of working for that person.

The dilemma is whether to be patient-directed, or patient-centred.  I hope I’m patient-centred.  That is I hope I listen well, share openly, and measure what I do transparently.  If a treatment approach isn’t working for this person at this time, using a hypothesis-testing approach to treatment at least means I can evaluate the elements I was working with, and begin again – if it’s a ‘preference’, ‘belief’, ‘assumption’ or responding to a sales pitch, then it’s not so easy to work out why it hasn’t worked.  And I can draw on the experiences of many clinicians, researchers and patients to inform my choice of intervention.

Naik, A., Dyer, C., Kunik, M., & McCullough, L. (2009). Patient Autonomy for the Management of Chronic Conditions: A Two-Component Re-Conceptualization The American Journal of Bioethics, 9 (2), 23-30 DOI: 10.1080/15265160802654111

Musings on theory and clinical work
This muse won’t be quite as lengthy as my last rant on occupational therapy and science, I promise! At the same time, it’s on a similar theme – and touches also on my post about ‘back to the basics’ where I discussed the recent review of pain contracts by ACC in New Zealand.  This review criticised the number of pain intervention services (eg injection therapies) and functional reactivation programmes that are provided without due regard to integrating the psychosocial along with the biomedical.  I suggested that perhaps providers need to be ‘risk profiled’ as well as claimants, because some of the behaviour seen in providers is likely to disregard high risk psychosocial factors and reinforce disability.

If clinicians are to be something other than ‘technicians’ applying a process to their patients, they (we) need to understand the concepts lying behind an intervention.  At the same time, we also need to be able to understand when an intervention isn’t likely to succeed, and when a variation on an intervention might suit better.  To do this requires effective clinical reasoning – aha! a theme!  I’ve hammered on a bit about clinical reasoning because it underpins the WHY we might choose to use one intervention over an other.  Clinical reasoning implies working backwards from what is evident in the patient’s presentation to hypothesise about how those features might occur.  In other words, developing a clinical theory to explain how and why the person is showing this behaviour.

Clinical reasoning can be quite straightforward in many settings.  After all, building on the knowledge of centuries, clinicians know enough about bone healing to align a broken bone, stabilise it, and wait for it to heal without doing too much thinking about it.  (Pssst! Don’t tell the orthopaedic surgeons this!)  Similarly, in an acute hospital setting, some fairly simple reasoning is needed to establish whether a person can get on and off the toilet with a raised toilet seat and then issue one if need be!  However, clinical reasoning can be (and usually is) much more complex than this.  Depending on their professional orientation, clinicians working with an acute fracture might ask why the person broke the bone, what the implications of that immobilised limb might be on occupations, might be considering the need for supports at home, might be monitoring for signs of shock – and the point is, these further interventions depend entirely on the theory-base of the clinicians working with that person.

Even in the case of someone needing a raised toilet seat in order to be discharged safely home, the clinical reasoning behind that simple intervention is not just about the biomechanics of getting on and off the toilet!  It could also be asking why the person has trouble standing up and keeping balanced, how the person might cope at night without lighting, whether the person can (or does) ask for help and so on.  Without having a good theoretical framework on which to base information collection, and a similarly effective way to organise that information, the clinician might as well simply issue a raised toilet seat and be done with it!

I’ve deliberately used simple examples to illustrate so-called simple clinical reasoning.  Now lets consider more complex examples.

Firstly, an analogy.  If I wear a set of glasses that occlude my vision on the left hand side of each visual field, I can still see. What I can see is limited, and I need to move my head around to scan the whole of my environment, but I can see.  After a while wearing these glasses, perhaps a week or so, finding my way around becomes easier, and in fact I’d have trouble after just another week of wearing the glasses, adjusting to ‘normal’ vision.  The world would look ‘normal’ to me even though part of my visual field is blocked.  New items appearing on the left side of my field of vision could suddenly ‘pop’ out of nowhere, and unless I know I’ve got those glasses on, I could be quite unaware of the amount of visual information I’m missing.

This is exactly what happens when a professional dons a single theoretical perspective.  I’m guessing we can all recall the first years of becoming a professional, and how strange adopting that new ‘persona’ felt.  After a while, though, it becomes familiar and we hardly notice it.  Then along comes new research, new theory, new models and new interventions.  The world gets a little shaken up!  We either integrate this new information, or we work hard to ignore it. ‘High risk’ clinicians are, IMHO, those who fail to recognise the contribution of information from outside their existing frame of reference. It’s my opinion that these clinicians can and should be identified, and either helped to integrate the new knowledge – or not allowed to practice in a field like pain management where the contribution of information obtained from so many fields is critical.

Bringing this back to clinical reality, if we are unaware of the theoretical models or even the professional models we use, we can be completely stumped when a new situation arises, or when a new piece of information is brought to light – a bit like that object coming into view on the left field of vision when I’m wearing those glasses!  By taking the glasses off, opening up the whole visual field, we can be much more aware of the fact that we do have constraints on what we can see, and if we look more broadly we can identify areas we want to look at in more detail.

OK, enough with the analogy.  Some clinicians scoff when I talk about my interest in science, theory, models and the process of clinical reasoning.  I think it’s vital.  Without articulating why a certain intervention is recommended, I think it’s impossible to distinguish between following a protocol as an assistant and being a versatile and adaptive clinician.  An assistant may not know how a process works, just that if (a) and (b) are following in a certain order, (c) will ensue.  If (g) or (h) are present, an assistant won’t know how to respond.  A good clinician knows that people may present with the same behaviour, but the underlying factors influencing that behaviour could be very different.  For example, someone saying that he or she can’t sleep and wakes often might be due to pain, a natural wakening during normal stages of sleep, having chronic sinus problems, low mood, anxiety – or even the effects of having a new baby in the house!  The work of clinical reasoning doesn’t start with simply ‘identifying the problem’ and then solving it: it begins with the way in which the clinician views the situation and the contributing factors.  If we’re not careful, even as experienced clinicians, we can jump to conclusions or simply ‘assume’ that the clinical problem is the one with which we’re most familiar, or the one that springs to mind the most easily.

It takes a lot of effort to avoid prematurely deciding on ‘what the problem is’ during a clinical intervention.  Being aware of our cognitive limitations, noticing our assumptions and broadening our view to include searching for as many different pieces of information as we can helps to prevent clinicians from working from a recipe – but it’s also hard work.

I’m referring back to Vertue and Haig’s paper on Abductive Theory of Method in clinical reasoning as the basis for today’s post. Read it if you’re keen on science, models, theory and clinical reasoning, and let me know what you think.

Frances M. Vertue, Brian D. Haig (2008). An abductive perspective on clinical reasoning and case formulation Journal of Clinical Psychology, 64 (9), 1046-1068 DOI: 10.1002/jclp.20504

Talking past each other? Models and interdisciplinary teams

As time passes, therapists can form their own way of working with people – sometimes we get away with this by calling our treatment models ‘eclectic’.  This can be a euphemism for ‘I’ll use whatever I think fits’, or even ‘I like doing this, so this is what I’ll do’!

While this may not be too troublesome if we’re working alone, when we work as a team, and particularly if we work in an interdisciplinary team with shared goals and common treatment approaches, it can mean we talk right past each other – especially if we use the same words, but mean totally different things!

For example, if we have team members assessing a person, unless they clearly define what they mean when they talk about assessing interpersonal/social aspects for example, they could well be looking at the situation entirely differently.

One may look at the impact of pain on the quality of relationships with others – perhaps discussing how clearly the person communicates with the other, how much satisfaction they have with their relationship, how supported they feel.

Another might look instead at the effect social interactions have on pain behaviour – what the family of origin did about pain, how responsive the partner is to reports of pain, and the effect this has on pain behaviour.

Still another might consider broader social issues such as the role of social agencies and relationships between the person and their health care team, maybe the person’s roles within the family and community, the effect of case management, issues of access to funding or treatment, or processes the person has to go through to keep getting income support and so on.

Hopefully they’ll consider all of these areas!

Similar differences exist in terms of assessing mood, anxiety, past mental health problems, current activity level, coping strategies and so on.  When teams work together it’s not just about using common words – it’s also about having a common understanding of the constructs  being used within a model.

There are probably several layers of model to consider too, just to complicate matters.

At the broadest level there is the biopsychosocial model – with differing emphases placed on each aspect of this model depending on training and orientation.

A model with a smaller focus might be a cognitive behavioural model of chronic pain – and there are more than one of these although they have common features.

A model with even smaller focus might be emotion regulation, which can form one of several models contributing to a cognitive behavioural model of chronic pain.

Beneath this, there could be several different approaches to emotion regulation, all of which may have something to contribute.

Each of these models has something to add to the management of chronic pain – but without careful definition and ‘translation’ from the jargon of one model to another, we can talk right past each other even within the same team.

Why bother with models at all?

Some people don’t articulate their treatment model – this doesn’t mean they don’t have one, simply that they’ve not made their model explicit. 

We all have assumptions about how and why we choose certain treatment approaches. (provided of course that we use clinical reasoning and don’t just follow a recipe book!) Models provide us with the conceptual basis for clinical reasoning – although IMHO they are broad brushstrokes that can be used to generate hypotheses about what might be happening for this person to present in this way at this time.  More about that later!

Models are theory – which is based on researched findings. As research continues to build a bigger and more detailed picture of how various aspects of a theory relate to each other, it can be modified – and in fact, needs to be.  Evidence can support or not support tenets of a model, and the model can be revised in the light of new evidence.  Which makes our clinical work both always new and always intriguing.

The patients we work with will have their own unique set of factors that inter-relate, and part of our work as clinicians is to identify the possible factors and their relationship to each other, test that out to see if the predictions from it hold true, then work with the person to modify the things that can be modified so their life changes.

If we’re working in a team, it’s important that we speak the same language AND have similar assumptions about how treatments might influence the person.

To add to this mix, we also have collected knowledge (from research) on what domains need to be considered in self management – and these are the domains we commonly work on to help a person take control of their destiny.  If a team doesn’t have some common understanding of the areas necessary for self management (or doesn’t agree on what self management looks like), again members can talk past each other.

This is one reason I’ve put the poll up on ‘what is self management’ – because I have a fair idea for myself on what it looks like, but I could be quite unique in terms of how I view it.

I’ll be scouting around for various models over the next little while – and discussing how new information can be integrated into models at least until the model needs to change significantly.  Kuhn called this shift a ‘paradigm shift‘, and I’m guessing that for most of us the paradigm shift in pain management was the introduction of the chronic model of pain, and integration of the biopsychosocial model.

Paradigm shift (or revolutionary science) is the term first used by Thomas Kuhn in his influential book The Structure of Scientific Revolutions (1962) to describe a change in basic assumptions within the ruling theory of science. It is in contrast to his idea of normal science. (Wikipedia)

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Thinking about thinking…

For a long time I thought everyone thought about what they think about, how they think about it, and what their thinking concluded – now I know that some people never do this and live on simply following the rules (and probably having a fun and relaxed time of it!).  I, on the other hand, have always spent time at the end of the day thinking about my thoughts and what they mean and how I come up with them.  The technical term for this is ‘metacognition’, or ‘thinking about thinking’, and it’s a strategy that can be really useful in cognitive therapy as well as pain management – and even more useful in your professional work as a therapist.

I started writing this post after reading this from the Skeptical Methodologist… in it The Skeptical Methodologist points out that although ‘…the scientific method as we know it from the enlightenment is a sound way to find truth about our world, we must always remember that the evidence we produce from any one experiment is only as good as the assumptions that went into it.’

What this means, is that if we don’t include our assumptions in any experimental method, we won’t be able to seriously critique our findings – our findings may only hold true in certain circumstances.  This doesn’t detract from the truth of those findings in those circumstances, but it does mean that we can’t generalise without risking making errors.  For more about this, read Ben Goldman’s article on How Myths Are Made.

If we’re unaware of our assumptions we may never look at our findings in the light of them – and this error is one I’m especially concerned about when I see exclusive reliance on  ‘self reflection’ and peer review of practice.

After all, if we have learned our professional skills from others within the profession, and even our professional peers haven’t had a broad or general knowledge of other approaches to treatment (or even to science), then we’re unlikely to know the assumptions that we hold. Sometimes it takes an ‘outsider’ or an interaction with another model or approach to help us look at what we assume is a ‘given’.  This can be challenging and sometimes disheartening – but can aid us in generating new and different ways of viewing our practice.  Think of general systems theory which came originally from engineering and has now influenced almost all the sciences including biology, chemistry, physics, sociology, psychology and health care!

Wikipedia states that: ‘Metacognition refers to a level of thinking that involves active control over the process of thinking that is used in learning situations. Planning the way to approach a learning task, monitoring comprehension, and evaluating the progress towards the completion of a task: these are skills that are metacognitive in their nature. Similarly, maintaining motivation to see a task to completion is also a metacognitive skill. The ability to become aware of distracting stimuli – both internal and external – and sustain effort over time also involves metacognitive or executive functions.’

Metacognitive monitoring and metacognitive control of emotional states have been suggested as a way for people with mood disorders and other behavioural disorders to take control of their illness.  The suggestion is that the person monitors his/her emotional state, applies a label to it, compares it to what they would really like to feel, and then takes action to make the current emotional state become closer to the goal state.  Another approach is to become aware of the thoughts – label them, recognise the emotions – then choose what actions to take that will ensure what is important (eg a value) is done.  This is one of the underlying strategies of ACT.

So, what does metacognition look like?

For me, it means forever asking questions about ‘why’.  Why do I take notice of this and this and this?  Why does that strategy work here but not here?  It means I become aware of my thoughts – then I can check my beliefs, and the foundations of those beliefs, test them for helpfulness (and accuracy!).   I can match those thoughs against whether they are helping me achieve what I want in my life, and often whether they’re even accurate.

In pain management, it can mean helping patients identify their thoughts – and especially, their anxious worrying or ruminating.  Metacognitive theory suggests that this approach developes into ‘cognitive attentional syndrome’ where the thinking actually focuses attention on emotional content and distracts from active coping.   ‘This pattern consists of worry, rumination, fixation of attention on threat, and coping behaviours that the person believes are helpful but many of which backfire and keep emotional problems going.’ Treating these problems using metacognitive therapy involves ‘helping patients develop new ways of controlling their attention, new ways of relating to negative thoughts and beliefs, and by modifying metacognitive beliefs that give rise to unhelpful thinking patterns.’ Sound familiar?

In other words, if we can help people become aware of what they’re thinking and that it’s unhelpful and probably based on unaccurate beliefs (and distinct from who they are), and we’re able to engage them in activities that are much more interesting and involving, they’ll be able to reorient themselves into a life they want to live.

But before we start employing metacognitive therapy in pain management, how about spending about 10 minutes after doing an assessment or a treatment – and thinking about your thinking?  What goes through your mind while you’re working with that person?  What are your assumptions?  Check out whether you’re assuming things on the basis of gender, age, ethnicity, occupation, even diagnosis.  You might be surprised at what you find out.

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