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…)

Coping strategies survey – the results 3!

Today’s post completes the results from my coping strategies survey by identifying how important the skills are in the respondent’s view. Remember these are all health professionals who work in pain management, and the questionnaire was completed online and confidentiallyskills-summary.

What you can see there is that the most important skill, as identified in this survey, is ‘Working with realistic thoughts’. What’s surprising about this is that respondents were not ALL psychologists! In some ways, this is probably one of the most important components in pain management because it encompasses all the cognitive elements involved in reconceptualising chronic pain from something that represents alarm and harm, into something that is simply ‘noise in the system’.

Self regulation was the next most important skill. This is the process of setting goals, and organising the ‘self’ to achieve them by modulating arousal level, establishing steps for moving forward, and working with feedback to persist with progress despite set backs. It’s interesting that self regulation is not mentioned at all in the documents I recently reviewed for ‘Intensive pain management programmes’ with a major purchaser of services in New Zealand. Self regulation is certainly something that is included in almost all the pain management programmes delivered at Burwood Pain Management Centre, although it may not be called that in so many words. It can masquerade as ‘goal setting’, ‘activity scheduling’ and ‘relaxation’ – all of which are components of the larger dimension of self regulation.

I was curious to see that task simplification scored as highly as it did. I think I mentioned that I rarely think of helping people develop this as a skill – as one respondent said, and I agree, it ‘infers avoidance’. I can see the value of task simplification in health conditions that have a gradually reducing level of energy such as multiple sclerosis, but chronic pain doesn’t need to have this prognosis. Task simplification suggests that simply by reducing activity level (or the strength or energy required to carry out a task), pain will reduce. Sadly, this isn’t so except in the short term, which is why resting is not recommended. Regulating activity level to ensure a consistent amount of activity is carried out through a day (rather than booming or busting, or being completely inactive – or even overactive) seems to be a more helpful approach, although it’s not easy to do.

Finally, although exercising brought all sorts of comments out of the woodwork when I asked about it earlier in the survey, it wasn’t thought to be the most important skill. At least nobody thought it was least important, but the majority thought it was either important or very important, with 3.8% of respondents indicating it was ‘critical’ (that must have been a physiotherapist!). Personally, I think activity can be substituted for exercise, provided that the activity can be carried out regularly, raises the heart rate, encourages full range of movement, and is fun!

I enjoyed conducting this survey. Even though the response rate was lower than I had hoped, it does provide you, reading this blog, some indication of what other professionals who also read this blog, think about coping strategies. I’ll be carrying out another survey soon, looking at goals and goal-setting – another area of pain management that is assumed to be great and helpful, but the process isn’t well-defined and deserves more investigation specific to pain management.

Coping strategies survey – the results 2!

Yesterday I started reviewing the coping strategies survey I’ve been running. 33 participants, a mix of health professionals – and some interesting results. Today I’m looking at when to use pain management strategies, and why.

Question 1 – Reducing pain behaviour has been recommended as a part of effective pain management. When do you think it should be encouraged?
24.1% When the person’s pain is at a ‘usual’ daily level

69.0% At all times, even during a flare-up of pain

6.9% When the person is around other people

Further comments:
As often as the person can sustain the focus without stressing out

Interesting responses to this question – I’m curious because I don’t read much specific information about how therapists typically address reducing pain behaviour.  I’ve personally used video, role play and the ‘pain thermometer’ – but I’m sure there are other ways.  I’d love to know how you do it – let me know via the comments section at the bottom of this post.

Question 2 – Assertiveness is part of effective communication, and has been included in many pain management programmes. When would you consider suggesting a client/patient should use this approach?

0.0% Never, assertiveness is not part of pain management

10.3% Only in situations where the person can cope with the consequences

24.1% At all times, honesty is the best policy

65.5% Selectively, when the person has the skills, energy and can cope with the consequences

Again, I was surprised at the responses to this question – what? No-one argued with me that assertiveness shouldn’t be included?!  I haven’t read much about this in my perambulations through the literature, so again I’d love to hear from you to see how you include communication skills in pain management.

Question 3Self regulation is defined as systematic efforts to direct thoughts, feelings, and actions, toward the attainment of an individual’s goals. Why would you include this in pain management?

40.7% To help the person focus on the future rather than on pain

63.0% To help the person become more able to implement coping strategies

18.5% To ensure the person maintains the use of newly acquired coping skills

Other comments:
To faciliate increased awareness of a persons responses to things and facilitate increase self-control and self efficacy.

Self regulation encompasses a large range of skills, and yes, I agree it needs to be included to help people move from being ‘patients’ to ‘people’, actively using their skills to achieve things they really want in their lives.  It does involve increasing the person’s awareness of their responses – and ability to adjust their responses to achieve the result they want.

Question 4 Most people participating in a chronic pain management programme will be encouraged to participate in a regular exercise schedule. Why would you encourage someone to exercise?

59.3% Exercise provides an opportunity to use pain management skills – especially task persistence

33.3% Exercise is good for reducing pain intensity

18.5% Exercise is easy to do on a regular basis so it encourages pacing

Other comments:
Maintains healthy lifestyle, holistic approach
For muscle strength, endurance, cardiovascular fitness, and because normal movement can impede pain signals
Maintaining an active component helps maintain general health and wellness
ALL! And mood elevation, and stress management…
Hope for some translation to improved function. Specific exercises movements can target fear avoidance and also improve general confidence with activity.
All of the above
Exercise in moderation and tailored to the patient is a necessary physical progression for health and a prophylactic against other maladies

Well, that brought you all out of the woodwork!  Exercise looks like it is an essential part of what health professionals think should be included in pain management.  As a confirmed exercise-free zone, it looks like I might have to sway to popular opinion!

Question 5 – Having chronic pain can be a very challenging experience. Cognitive therapy emphasises the role of realistic thoughts. When a person’s thought is realistic, but not helpful, would you challenge their thinking?

14.8% Yes – they may still be using maladaptive thinking patterns

7.4% No – it’s difficult to argue against reality

81.5% Yes – but not to challenge the reality, just to establish a more helpful view of the situation

I was curious to see that some people wouldn’t use cognitive therapy to help people develop a more helpful view of their situation.  While a person might be describing ‘reality’ to them, simply acknowledging this without checking out that the thought is helping them achieve goals may produce a ‘reality’ that is more negative than it needs to be.  I’m reminded of an illustration someone once gave of a line-up of swimmers at the beginning of a race – do they look left, they look right and say ‘Oh no, everyone else is bigger than me, what chance do I have?’, no!! ‘They say ‘I’m going out there to go, go, go!’

My last post will be tomorrow – looking at the ratings of importance for each of the coping strategies.  See you then!

Pain Management Skills Survey

Something we don’t know very much about is the way health professionals view the type of coping skills that are often recommended for patients.
This survey is one way to start to learn more about what you as a health professional think about some of the coping skills commonly used in pain management.
It’s completely confidential, very quick to complete, and I promise it has absolutely no nutritional value!

Click on this link and I promise it’ll be painless…

And in a couple of months, when I reach my target number of participants, I’ll post the results!

thanks heaps for doing this!

Science and therapists

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Renewing the Scientist Practitioner Model D. Shapiro, 2002

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

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

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

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See you again soon…