values

What is pain for?


We’re told we need pain – without the experience, we risk harming our bodies and living short lives. With pain, and for most people, we learn to not go there, don’t do that, don’t do that AGAIN, and look at that person – don’t do what they’re doing! Thirst, hunger, fear, delicious tastes and smells, the feelings of belonging, of safety and security, of calm and comfort: all of these are experiences we learn about as we develop greater control over our bodies.

Pain is an experience we learn to associate with actual or possible threat to “self”. Let’s take a moment to think about what “self-hood” means.

If I ask you “who are you?” you’ll tell me your name, probably your occupation, maybe where you live and who you live with. Baumeister (1997) suggests our sense of self is about “the direct feeling each person has of privileged access to his or her own thoughts and feelings and sensations.” He goes on to say “it begins with the awareness of one’s own body and is augmented by the sense of being able to make choices and initiate action.” We learn about who we are through interacting with the environment, but also as we interact with other people and begin to sort through our roles, contributions and relationships.

Of course, our sense of self changes over time and is reciprocally influenced by choices we make as well as opportunities (and threats) around us, both environmental and social.

We work really hard to avoid threats to our sense of self. For example, I’ll bet we’ve all seen that person who steadfastly refuses to stop colouring his hair, wearing the same clothing styles as he did in his 20’s, holding on to the same habits as he did at the same age even when he’s now in his 50’s, has a paunch, and still looks for partners 20 years younger than he is…  He still believes he’s that young stud despite the evidence in the mirror. And of course the same applies to women perhaps more so!

So what happens when our mind/body is threatened? How do we know it? And what do we do about it?

In this instance I’m not talking about social threats, though there’s interesting research suggesting that being socially excluded has similar neurobiological effects as being physically threatened (or experiencing pain – though this may reflect the distress we experience when we’re hurt and when we’re socially excluded – see Iannetti, Salomons, Moayedi, Mouraux & Davis, 2013; Eisenberger, 2015). I’m instead talking about threats to our physical body. Those threats may be violence from another person, physical trauma to the body, or the threat of physical harm to the body. When we experience these kinds of threats, and once an aspect of mind/body has disentangled the threat evaluation from whatever other goals we’re currently engaged in, we experience pain. Tabor, Keogh and Eccelston (Pain, in press) define pain in terms of action: an experience which, as part of a protective strategy, attempts to defend one’s self in the presence of inferred threat.

So pain is there to help us maintain an intact sense of self in the presence of threat – threat that we’ve inferred from our context (or drawn a conclusion from incomplete data). It’s part of a system that works to maintain “us” in the face of multiple threats that we encounter.

Tabor, Keogh and Eccleston also argue that pain is an experience designed to intrude on awareness to show that “boundaries have been reached and action must be taken”. Pain is one way our mind/body can give us an indication of boundary – just how much, or how little, we can do. For example, I experience pain when I bend my thumb down to reach my wrist – it’s one way I can learn how far I can bend without disrupting something! The purpose of that pain is to help “me” defend against doing really dumb things, like stretching my thumb out of joint!

Interestingly, when we feel overwhelmed by our pain, when we can’t defend against it (because it feels too intense, has meanings that threaten our deepest sense of self) we tend to withdraw from responding to everything else – our conversations stop, we don’t notice other people or events, we pull into ourselves and ultimately, we can lose consciousness (think of the accounts of early surgery without anaesthesia – the surgeons were kinda grateful when the patient lapsed into unconsciousness because at last they weren’t writhing to get away – see Joanna Bourke’s book “The Story of Pain” for some harrowing stories!).

When we lose consciousness, our sense of self disappears. We lose contact with the “what it is to be me”.

Our sense of self also disappears when we experience pain we can’t escape and we can’t make sense of. Throughout the time while people are trying to label their pain, establish the meaning of their symptoms, and while people are searching for a solution to their pain, people’s experience of both time and “who I am” is threatened (Hellstrom, 2001).

To me, this is one of the primary problems associated with pain – and one we’ve almost completely ignored in our healthcare treatments. All our treatments are aimed at helping “get rid of the pain” – but what isn’t so often incorporated in these efforts is a way of engaging and rebuilding a resilient sense of self. So while the pain may ebb away, the “self” remains feeling vulnerable and threatened, especially if there’s any hint of pain returning.

What can we do better? Perhaps talk about what vision a person has of themselves as a “self”. Help them work towards becoming the “self” they believe they are – or at least helping them express the underlying values that their “self” has previously been expressing. That way perhaps people can find flexible ways to express that “self” – which will make them more capable of living well under any circumstances.

 

Baumeister, R. F. (1997). Identity, self-concept, and self-esteem: The self lost and found. Hogan, Robert [Ed], 681-710.

Bourke, J. (2014). The story of pain: From prayer to painkillers: Oxford University Press.

Eisenberger, N. I. (2015). Social pain and the brain: Controversies, questions, and where to go from here. Annual review of psychology, 66, 601-629.

Hellstrom, C. (2001). Temporal dimensions of the self-concept: Entrapped and possible selves in chronic pain. Psychology & Health, 16(1), 111-124. doi:http://dx.doi.org/10.1080/08870440108405493

Iannetti, G. D., Salomons, T. V., Moayedi, M., Mouraux, A., & Davis, K. D. (2013). Beyond metaphor: Contrasting mechanisms of social and physical pain. Trends in Cognitive Sciences, 17(8), 371-378.

Tabor, A., Keogh, E. and Eccleston, C. (2016) Embodied pain— negotiating the boundaries of possible action. Pain. ISSN 0304- 3959 (In Press)

On the value of doing, being and becoming


An old occupational therapy tagline was “doing, being, becoming”. The meaning of this phrase is intended to point to the tight relationship between what we do, who we are, and how we develop and grow. As I read blogs discussing an increased emphasis on “real world” outcomes there is something missing from the narratives: that intangible quality that marks the difference between colouring in – and painting. Or filling in a form – and writing a poem. Going from room to room – and dancing. Something about expressing who we are and what we value.

Values are things we hold dear. They are principles, or “desired qualities of behaviour”, life directions (not destinations).

The things we do (our actions) are inevitably infused with our values because how we do things (sloppily, carefully, neatly, with gay abandon, enthusiastically) is an expression of what we think is important. To give you an example, I occasionally vacuum my house. Sometimes I’ll do it really thoroughly – because I love seeing a sparkling house. Sometimes I’ll do it with a flick and a promise – because it’s a beautiful day and I want to get out of the house. In both instances I’ve expressed something about what is important to me – I do enjoy seeing my home looking tidy and organised. I don’t have to have reasons for liking my home this way, I just do. When I do a quick flick through my home it’s not because I’m lazy or I don’t care, it’s because I value getting out of the house more than I value having a tidy and organised home on that day.

Values don’t have to be explained. We don’t have to have reasons for holding them. They’re something we choose to place as important.

Why be concerned about values? Well, they underpin our choices. They provide motivation towards some activities, and away from others.

There is a lot of emphasis at the moment on people with osteoarthritis “getting fit” and “doing exercise”. The current approach in New Zealand is to provide community-based programmes to people who have just been declined joint replacement surgery (because we can’t offer surgery to everyone who wants it). Uptake hasn’t been enormous, and to be honest I’m not surprised. People who haven’t been exercisers are not very likely to begin an exercise programme that is undoubtedly going to increase their pain in the short-term (because, duh, movement hurts!) even if the programme offers hope of improved pain and function in the future. Putting this into a “values” and “motivation” perspective, people usually value comfort over discomfort. They value short-term outcomes over long. If they’ve never exercised much, it’s clear that exercise isn’t something they value. To help them engage in an exercise programme, we need to work hard to identify values they hold dear so they’ll look to those to over-ride the value of comfort over discomfort.

An alternative might be to think of different ways of expressing values that will concurrently meet the goal of increased exercise. For example, I don’t enjoy exercise per se. In fact I’ve boasted that my body is an exercise-free zone! To tell the truth, that’s not exactly the case. I just don’t do “exercises”. Instead I dance. I get out of my chair for five minutes every 20 minutes and go do something involving my whole body. I garden. I play with the dog. I go out in the kayak. I walk miles when I’m fishing.

Some people would argue that “there’s no evidence base for this” – but I think we’ve forgotten that exercises are simply a planned and repetitive form of moving our bodies because we don’t do that nearly as much in modern times as we used to even in the early 1900’s, let alone in stone-age times. I don’t think hunter-gatherers “do exercises” except as training for something like war or hunting (to increase skill).

Living life with chronic pain must become a lifestyle. And it needs to be a lifestyle that has some life to it – not an endless series of “things we must do for health”, unless “health” is a particular value. If life is just about “things we do for health” doesn’t that constantly remind people of what they don’t have? That they’re not healthy? Making them patients instead of people? For most people, to be healthy is a means to an end: they want to connect with family, express who they are, contribute to their society, love and be loved. If the person in front of us isn’t into exercise, it’s OUR job to work out what they value and connect what we think is important to what they think is important, or we will simply fail.

Some simple steps to identify values – try these out in the clinic!

  1. When a person attends your clinic, they’re expressing a value, that they care about something. Asking the person “what do you hope from coming to see me” is a pretty common opening line. Try extending this by, after they’ve answered, asking “why is that important to you?” or “what would it mean you could do” or “how would that make a difference to you?”
  2. If a person says they don’t like something, try suggesting to them that they value the exact opposite. eg if they’ve said they really don’t like running, ask them why: “it’s boring” might be the answer. This answer suggests they like variety and excitement in their exercise routine. Then you can ask them what activities they see as exciting – maybe instead of running, they’d enjoy virtual boxing (bring out the Oculus Prime!), or a scavenger hunt, or geocaching.
  3. Use the 1 – 10 “readiness ruler” technique from Motivational Interviewing. Ask the person to draw a line and put 1 at one end, and 10 at the other. 1 = not at all important and 10 = incredibly important. Then ask them to put a cross on the line to indicate the importance they place on doing exercise/healthy living/pain management (whatever you’re asking them to do). Then (and this is important!) ask them why they put that mark so high. This is important – even if that mark is down on 2!! Ask them why they put it there and not lower. This will help elicit important values that you can then use to connect what you want them to do with what they value.

End-of-year musings


It’s my last post for the year. It has been an extraordinary year, lots of surprises, shocks and enough excitement for anyone! I’m not even going to start on the political changes, here in NZ we’ve had yet another major earthquake, excitement as ACC (our national accident insurer) sets up new pain service contracts (with a LOT of people who haven’t been involved in pain management before… there’s an experiment in the making!), and continuing road cone carnage on the streets of Christchurch.

On the pain news front, I can’t think of any incredibly ground-breaking news – although one medic advised that “Virtually all cases of low back pain can now be diagnosed definitively by criterion standard methods as to source and cause.” That same medic also argued that a paper by Maher, Underwood & Buchbinder (2016) on non-specific low back pain, published in The Lancet, represented “the views of non-evidence-based troglodytes who (a) have apparently not read any scientific papers since 1966, and (b) have vested interests in “managing” non-diagnosed patients so their practices remain busy and they reinforce each other’s views that the burden of low back pain cannot be eased.” I’ll leave the critiquing of that view to those with more time and energy than I have!

It’s also been a year in which various commentators have critiqued the “biopsychosocial model” as it’s applied in musculoskeletal pain.  Some have pointed out that this is an unscientific model, it’s not a theory that can be tested and therefore can’t point to “truth” or whatever approximation we can currently identify. Others have argued that by adopting this framework, practitioners must either be versed in “life, the universe and everything” – or perhaps become exactly what advocates of this approach decry: reductionists. I’m not sure I follow this argument, but those that raise it are intelligent, articulate and far more thoughtful than those who believe that Maher, Underwood & Buchbinder are “troglodytes” or have “vested interests”.

I continue to hold that a biopsychosocial perspective explains more, and is of practical use when we consider the various factors that might influence why this person is presenting in this way at this time, and what might be done to reduce their distress and disability. Here’s my take.

Biopsychosocial model

When we look into the original biopsychosocial model, we need to understand the context in which Engel first developed it. He was a psychiatrist, and at the time psychiatry was under threat from psychologists in particular, who were strongly advocating that many mental illnesses were actually “problems of living”. Things like alcohol abuse, forms of mood disorder, relationship issues and the like were seen as disorders influenced by learning and environment rather than biology. Psychiatrists were perhaps on the way to being sidelined from the very area in which they claim expertise. Engel, influenced by general systems theory and cybernetics, proposed a way for psychiatrists to remain relevant: look at the person as part of a wider system in which each element in the system could influence and be influenced by the next. Engel used this approach as a way to frame conversations with the patients he saw – attempting to understand how and why they were seeking help, and especially, attempting to understand the person and his or her priorities. I think that’s admirable.

How the model has evolved since then is an interesting tale. I first encountered the model during my occupational therapy training, where it was a foundation to viewing people-in-context. It was presented as a bit old hat (I started training in 1979), and was replaced in my profession by Gary Kielhofner’s Model of Human Occupation. This model similarly draws on general systems theory, and argues for the relevance of volition and habits as well as capacity from a biological/performance stance to undertake occupation and of course, contexts such as environment which includes the social environment. MOHO incorporates much of what we consider to be biopsychosocial – in fact, occupational therapy as a profession is based on the idea that people actively engage in purposeful and meaningful activities (occupations) that are formed out of the affordances available to them by virtue of biology, psychology and social elements within an environmental context.

So what?

For a model, or theory, to have value it needs to offer something that existing models or theories don’t. It needs to be more parsimonious (make fewer assumptions), explain more (be more consilient), hold together with existing knowledge (cohere), and predict more (Thagard, 1978).

For a clinician, a theory must also be useful in terms of explaining why this person is presenting in this way at this time, and directing what can be done to reduce distress and disability. Why these questions? Because people actively make decisions to seek treatment. They evaluate their experience in light of their past experiences, prevailing community beliefs about the trajectory of their problem, family influences, and yes, legislative influences. These are possibly more important than the biology of their problem – because we’re not going to treat someone who doesn’t believe they have a problem!

As clinicians I think we need to ponder exactly what we consider to be “treatment”.

When my fracture is reduced and immobilised, that is “treatment” – but it’s not actually ‘healing’ my bones, it’s actually up to my body to do the work. What immobilisation does is create an environment in which my body can heal itself. But the problem of a broken bone is not “treated” just by immobilisation. Treatment has to include the rest of my recovery – and involve prevention strategies too. My recovery will need to include restoring function. And some of that restoration will be by guiding me through various movements that increase tissue tolerance as well as my confidence that my limb will support me. My recovery also has to include me understanding and learning from my experience – will I jump off that cliff again? Will I leave the toys all over the floor again? Will I walk on a slippery path again?

I think clinicians simply create an environment in which people can recover. And we need to go beyond measuring range of movement or strength to establish that recovery has occurred. Recovery isn’t just about returning to “normal” whatever that is. It’s about moving beyond this interruption and into new possibilities and new challenges. It’s really about being able to be who we really are. While that’s primarily the person’s own responsibility, our job as clinicians is to create an environment where it’s possible. While a biopsychosocial model/theory/framework makes life complex, using this approach allows us to be aware of more of the factors relevant to recovery and growth than simply looking at people as if they’re bits of meat, bone, and juice.

In the new year

I’ve been blogging since 2007. In that time I’ve written over a thousand posts all on the topic of pain. Almost all of my posts are on the theme of how we can remember that we are working with people. Other human beings who have their own thoughts, beliefs and priorities. Humans who make sense of their situation as best they can. People who, like us, hold cognitive biases, and feel emotions, and get stuck, and hold values. My real focus is on how we can integrate these things into clinical reasoning – because until we do, we’re ignoring what matters most to the people we seek to serve.

 

Engel, G. L. (1977). The need for a new medical model: A challenge for biomedicine. Science, 196(4286), 129-136. doi:10.1126/science.847460

Maher, C., Underwood, M., & Buchbinder, R. (2016). Non-specific low back pain.  The Lancet. doi:10.1016/S0140-6736(16)30970-9

Thagard, P. R. (1978). The best explanation: Criteria for theory choice. The Journal of Philosophy, 75(2), 76-92.

Ups and downs and rocking and rolling


What a week it has been! Not only an unexpected result in the US elections, but also a very large earthquake north of Christchurch, along with a tsunami alert for the entire eastern coastline of New Zealand. Luckily I live far enough away from the shoreline that I didn’t have to evacuate, but the sirens certainly work!

As a result of these events, which I firmly believe are NOT associated except in time, the post I was going to make seems a bit redundant, so I’m going to talk about resilience and what it really means.

For someone who has lived through thousands of earthquakes since September 2010, resilience is almost a dirty word. People living in Christchurch are a bit tired of being called resilient.  You see, it’s not the quakes that are the problem – it’s the aftermath. The “new normal” that we’ve been living through these past years. The thousands of road cones lining almost every street. The constant detours as bits of road are dug up and sewerage, storm water and water pipes relaid. The delays. The ongoing processing needed to work out “where am I?” in the streets we used to know so well.

Resilience is intended to refer to “bounce back”. The thing is, I don’t think we bounce back to exactly the way we were before – we’re irrevocably changed by all experiences, but especially ones as significant as the earthquakes, or even political changes. That we don’t “return to normal” is one of the main reasons I don’t believe reports of people “going back to normal” if pain is completely removed. Why? Because people actively process and make meaning from everything that happens to them – and the meanings that are given to experiences don’t ever completely go.  We know, for example, that we can’t “unwire” nerves that have fired together, so what actually happens is that alternative paths or connections between nerves are formed. This means that under the right circumstances, those original paths will fire again… And people who have experienced chronic pain will, even if their pain eventually goes, know exactly what that pain meant, how it affected them, and I’m certain will be very aware of any new pain that seems to be similar to the one that was just there.

Resilience to me is therefore not so much about “bouncing back” as it is about being able to take stock of what actually IS, determine the paths that lead on in the direction of important values, and then choosing to take those paths. And this can often mean taking detours because old paths aren’t negotiable any more. That can be, and is, disturbing. It can be frustrating, fatiguing and far more demanding than the idea usually invoked by the word “resilience”.

So, in the next days and weeks, let’s think less about being resilient, and more about being flexible – flexibly persisting, if you will. We need to persist to get anywhere, do anything. We need to be flexible about how we get there and how we do what we value. We’ll need passion, but more than passion, we’ll need commitment.

 

When do we need to say we’ve done enough?


This post is food for thought for both clinicians and people living with pain. It has come about because of a conversation on Facebook where some clinicians felt that people with pain are only being offered the option to “learn to live with pain” when their pain intensity could either be reduced or go completely.  And this conversation is one repeated countless times around the world when those living with persistent pain seek help for their disability and distress.

I’m going to declare my hand right now: I think a the problem in chronic pain management isn’t that people get offered “pain management” or “learning to live with pain” or “accepting pain” too often – I think it’s not happening often enough, nor soon enough. But let me unpack this a little more…

We know that in New Zealand at least one person in every six lives with chronic pain that has gone on for more than six months (Dominick, Blyth & Nicholas, 2011). We also know the seven day prevalence of low back pain in New Zealand is 35% (men) and 48% (women) (Petrie, Faasse, Crichton & Grey, 2014).

Treatments for painful conditions abound. From the simple over-the-counter approach (medication, anti-inflammatory creams, hot packs, cold packs) to hands-on therapies (massage, osteopathy, chiropractic, physiotherapy), to exercise therapies (Pilates, core strengthening, gym programmes, spin classes, walking, exercise in water), and finally to the multitude of invasive therapies (injections, neurotomies, decompression surgery, fusion). There is no shortage of treatments that aim to get rid of pain, fix the problem and get life back to normal. And for the most part these treatments provide modest improvement in both pain intensity and functional gains. For low back pain it seems there is no single wonderful treatment that works for everyone – hence the proliferation of treatments! (cos if there was a single treatment that worked, we’d all be offering it – like we do with a broken bone or appendicitis).

Here’s a question: if pain “management” (ie helping people learn to live with their pain) was the main offering to people living with pain, wouldn’t there be a heap of places to get this kind of treatment? At least in New Zealand there are relatively few pain management centres although there are many, many places to go for pain reduction.

I’ve tried to find studies looking at how people are told they have persistent pain that won’t be cured. Strangely, I have had incredible difficulty finding such studies. They may be there in the research literature – but they’re fairly uncommon and hard to find. And given how poorly low back pain guidelines are followed despite being promulgated since at least 1997, even if there were studies examining the best way to convey this news, I’d be surprised if anything was routinely incorporated into clinical practice.

So, in my opinion there are many more clinicians offering to help reduce pain than there are those offering to help people “learn how to live with pain”.

I was asked recently “when you do decide to stop pursuing pain reduction?” I think I said “it’s ultimately the decision of the person living with pain” – but it’s complicated by the way we as a culture perceive this option. I think most people would be horrified to think “I’m going to have a lifetime of living like this” when our beliefs about pain are influenced by and attitude that “pain = suffering”, “pain is unnatural”, “pain is a sign of something badly wrong”, “pain is something to get rid of”. I know when I was told “I’m sorry but there’s nothing more we can do for your pain” I was terribly upset thinking I had a lifetime of feeling awful to look forward to! I was 22 and had low back pain that would not go away after 18 months. I’m now 52 and I still have pain – but I can tell you that I have done almost everything I’ve wanted to including SCUBA diving, tramping, fishing, dancing, working full time (overtime), and parenting.

When do we begin to think about living with pain rather than curing it? I think we need to take a hard look at what this sentence means.

Firstly it means living. Life continues whether we’re feeling like we’re moving forward, or we’re putting things on hold to pursue a particular goal. Life doesn’t actually stop – but the things we want to experience, the things we want to do change over time. Our focus at the age of 22 is quite different from our focus at age 52 – and I hope it will change again at age 82! We don’t get to hit the replay button and live life all over again. We get one shot at it. This could feel quite awful if we’re contemplating a life where looking for pain relief is our primary goal – especially when that process involves an endless round of hope then despair as treatments are tried – and then don’t quite work out. Even the process of looking for treatments is slow, fraught with anxiety, and it eats up time in a week. For me, taking time out from living to pursue a treatment that may work means a process of weighing up the costs against the benefits. The costs include time, energy, emotional investment in the result, and the discomfort of the treatment itself. The benefits? Well, that depends.

The second part of that sentence is “with”. Living with pain. To me this means establishing my willingness to experience something I don’t enjoy – and believe me, I’m not a fan of pain! If all I have to look forward to is pain, pain, pain I’m not keen on doing it. BUT I am keen on living and bringing pain along with me (because frankly, my pain is coming along for the ride anyway). Living with pain to me means making room to experience pain fluctuations while doing things that bring value and meaning to my life. It means I ache – but I have a beautiful garden. I have sore legs – but I’ve been dancing. I have an aching back and neck and arms – but my house is clean. Here’s the thing: even if I didn’t work in my garden, dance or clean my house I’d STILL be sore! And I’d be bored, feel like I hadn’t achieved anything, and would have had to ask other people to help because many of those things still need doing.

The thing is, pain ≠ suffering.

When do we make a decision to stop pursuing pain reduction? Well, if I’m honest I’m still on the lookout for something that will help reduce my pain. And I think anyone who does live with persistent pain would agree that we don’t really want to have this experience, just like people who have cancer don’t want it, or diabetes or stroke or any of the myriad other chronic conditions humans are prone to getting, especially as we age. When asked, I’m sure most people with chronic pain would say “Yes” to pain reduction as a goal. BUT, and this is important, living life as fully and richly as we can is just as important.  I would bet that anyone with any of those chronic conditions would also just love to have them cured too.

But pain is a funny thing, there are myths and unhelpful beliefs coming from clinicians and our cultural norms about pain being a bad thing that must go. Compared with the beliefs and attitudes about other chronic conditions, this is unhelpful. We don’t find health professionals constantly pursuing treatments to “get rid of” diabetes, the focus is on management. And we accept that people who have cancer may choose to no longer accept treatment – and we support them by providing good hospice care. How often do people with chronic pain get (a) support to make a decision to live with their pain and (b) support to learn to do this well without feeling like second class citizens who have failed. We even have a group of clinicians calling people who haven’t responded to their treatments “failed back syndrome” as if the person’s back has failed rather than the treatment failing.

What makes me decide to pursue a new treatment that promises to reduce my pain? Well, it has to fit into my life. It can’t interfere with what’s important to me in terms of time, energy or discomfort. The odds need to be pretty good for me to even look at it – I want to see more than a single research paper showing its effectiveness. I would have to trust the clinician, and they’d have to respect me and my lifestyle and priorities. I’d want to make sure that clinician was going to stick with me and help me decide whether it’s worth doing. I’d want to see that the treatment would help me achieve my goals and priorities – otherwise I’m not really interested.

Is this because I’m weird (say yes!)? Or that I have less intense pain than other people? (nope, because you can’t compare my pain with anyone else’s, and because pain intensity ratings are strongly influenced by distress, mood, anxiety, how much pain interferes with life, attention, culture yada yada yada (Linton & Shaw, 2011). I think it’s because right now I’m too busy living, I get more joy and satisfaction from doing things that make me feel like myself. But remember I’ve been doing this since I was 22. And it’s a process. And I’m weird. I am a pain geek.

The thing is, unless clinicians promote living well with pain as an equally valid option to trying to get rid of it, people will continue to think that it’s impossible to have a really good life unless their pain is gone. And that, to me, is a tragedy, because we only have one life to live.

 

Dominick, C., Blyth, F., & Nicholas, M. (2011). Patterns of chronic pain in the New Zealand population. New Zealand Medical Journal, 124(1337), 63-76.

Linton, S. J., & Shaw, W. S. (2011). Impact of psychological factors in the experience of pain. Physical Therapy, 91(5), 700-711. doi:10.2522/ptj.20100330

Petrie KJ, Faasse K, Crichton F, Grey A. How Common Are Symptoms? Evidence from a New Zealand National Telephone Survey. BMJ Open. 2014;4(6). doi: 10.1136/bmjopen-2014-005374.

Clinical reasoning “think aloud”


Occupational therapists are keen on helping people return to doing the things they value – meaningful activity, or participating in valued occupations (same thing, essentially). So, a person might come to see me because they have low back pain and want to work out how to get to work.

My first step is to understand what it is about the back pain that seems to be stopping the person from doing the tasks involved in their work. I usually begin by taking a history – what does the person understand about how their back pain came on, what’s their theory as to why it’s there, what have they done to help their recovery, how are they managing the everyday things they need to do right now. I ask about sleep, sex, personal care, daily routine, and in doing so I’m finding out about the person’s beliefs and attitudes towards their pain, their ability to regulate their arousal level, their mood, their confidence, the influence of others around them (both supportive – and those more subtle influences like their response when the person does something). I’m very careful to try to understand the contexts in which the person is having trouble – and what factors in the context might be supporting change.

In my mind I’m trying to establish a set of possible reasons for this person coming to see me at this time and in this way. I’m running through the various influences I know affect a person’s ability to engage in normal daily activities. Because I have a strong psychology background, I’ll consider functional behavioural analysis, but I’m also sensitive to personal values, cultural norms, and yes, even biological factors such as strength, range of movement, and motor control.

I can try to influence two things: the demands of the tasks in the context of work, and the capabilities of the person, but I need to keep a couple of things in mind.

  1. What is the effect of my intervention in the medium to long-term, not just the short-term?
  2. What does this person need in this context right now?

Depending on my clinical formulation, and the overall theoretical model I’m using, I can approach the decision-making in many different ways. As you’ve probably guessed, I’m a fan of Acceptance and Commitment Therapy, so my end goal is to help this person develop the ability to respond flexibly to the demands of any situation. I want to keep in mind that what I do now can have a long-term influence on what they’ll do over time. Some occupational therapists may instead focus primarily on “what will solve the problem for this person right now” without always thinking about the long-term impact.  As a result, we can see some people with low back pain being given special seating, perhaps a new bed, some adaptive equipment so they can achieve the goal of “doing” – but at the same time, being unaware of the constraints this can put on the person being able to participate in other contexts.

For example, if my client is having trouble getting to work because he thinks his car’s seat should be fixed. If my focus was purely on helping him drive his car in comfort, I could consider assessing his car and giving him some cushioning to make it more supportive. There, problem fixed! But, let’s take a look at the effect of that intervention in the medium term. While he can drive to and from work, he’s learned that he “needs” a special seat or cushioning to help stop his discomfort. He’s also learned that his back pain is something he “shouldn’t” experience.

Based on what he’s learned from my intervention, what do you think can happen if he continues to experience back pain in the work setting?

His personal model of pain will have developed a couple of interesting quirks (and ones we often see in clients) – he’s learned that posture influences his back pain, and that there is a posture that “fixes” it. He’s learned that he should have his back in a particular position to be comfortable. He’s also learned that because he can influence his sitting position in the car, he “should” be able to influence his sitting position in other contexts – like, perhaps, his office desk or the seat in his digger. He might even, if his belief that his back “should” be in a particular position is especially strong, begin to try to keep his back in this position while doing other activities like walking or carrying things, or using tools. Most insidiously, he has learned that his back pain is something he should not have. It’s a sign to him that he has to “fix” his sitting position or he’s doing something wrong. But back pain is common, many factors influence it, and it often doesn’t settle completely.

If I instead want him to be able to respond flexibly to many different settings, I’ll need to think more carefully about my intervention. My underlying reasoning has to capture the workability of any suggestions I make – and workability not just in the car while driving, but at work, while doing other tasks, at other times.

I may work together with him to find out what it is about the pain in his back that particularly bothers him. Pain itself is usually not the problem – it’s what the pain represents, the effect on doing things both here and now, and in the future. In my client’s case, perhaps his back pain is particularly frustrating for him because he values getting to work and feeling ready for anything. He doesn’t want to feel like his goals are being blocked (he doesn’t want to feel exhausted and not ready for work), he doesn’t want his back pain, and his mind is telling him he needs to be “ready for anything” even though he is in the middle of a bout of back pain. In ACT terms, he’s avoiding the negative feeling of frustration, of potential failure, of feeling exhausted and his back pain, and he’s doing what all humans do – trying to control those emotions so that he doesn’t feel them! Makes perfect sense – except that the solution (giving him a cushion for his vehicle) could pose its own problems.

I can position my intervention in a couple of different ways. Honouring the value he places on being ready for anything at work, I can talk to him about how well that’s working for him right now, given he’s having a bout of back pain. Could he be willing to allow himself to be less “ready for anything” while he recovers from his back pain? I could also suggest that he could take the time to be present to his back pain, to be aware of and experience his back – and his feet, arms, shoulders and breath – while driving to work, so that he can notice the times when it’s really bothering him, and when it bothers him less, and that along with his back pain he also has areas of comfort and strength. I could provide him with a cushion – but ask him to think about what happens when he has to sit in other chairs, and ask about the workability of carrying a cushion wherever he goes.

The point is that while occupational therapists can help people do the things they want and need to do, some of our efforts can constrain people’s options over time. We don’t live the lives of our clients – but sometimes we can assume the client’s priority is to solve an immediate problem, while overlooking the other competing values the person also holds dear.

I’ve included some readings that have informed this blog post – while they’re not directly referenced in my post, they help inform my clinical reasoning.

Damsgard, E., Dewar, A., Roe, C., & Hamran, T. (2011). Staying active despite pain: Pain beliefs and experiences with activity-related pain in patients with chronic musculoskeletal pain. Scandinavian Journal of Caring Sciences, 25(1), 108-116. doi: 10.1111/j.1471-6712.2010.00798.x

DeGood, Douglas E., & Cook, Andrew J. (2011). Psychosocial assessment: Comprehensive measures and measures specific to pain beliefs and coping. Turk, Dennis C [Ed], 67-97.

McCracken, Lance M., & Vowles, Kevin E. (2014). Acceptance and Commitment Therapy and Mindfulness for Chronic Pain: Model, Process, and Progress. American Psychologist, 69(2), 178-187.

Stenberg, Gunilla, Fjellman-Wiklund, Anncristine, & Ahlgren, Christina. (2014). ‘I am afraid to make the damage worse’ – fear of engaging in physical activity among patients with neck or back pain – a gender perspective. Scandinavian Journal of Caring Sciences, 28(1), 146-154. doi: 10.1111/scs.12043

Trompetter, Hester R., ten Klooster, Peter M., Schreurs, Karlein M., Fledderus, Martine, Westerhof, Gerben J., & Bohlmeijer, Ernst T. (2013). Measuring values and committed action with the Engaged Living Scale (ELS): Psychometric evaluation in a nonclinical sample and a chronic pain sample. Psychological Assessment, 25(4), 1235-1246.

van Huet, H, & Williams, D. (2007). Self-Beliefs About Pain and Occupational Performance: A Comparison of Two Measures Used in a Pain Management Program. OTJR: Occupation, Participation and Health Vol 27(1) Win 2007, 4-12.

Did it help? Questions and debate in pain measurement


Pain intensity, quality and location are three important domains to consider in pain measurement. And in our kete*of assessment tools we have many to choose from! A current debate (ongoing debate?) in the august pages of Pain (International Association for the Study of Pain) journal shows that the issue of how best to collate the various facets of our experience of pain is far from decided – or even understood.

The McGill Pain Questionnaire (MPQ) is one of the most venerable old measurement instruments in the pain world.  It is designed to evaluate the qualities of pain – the “what does it feel like” of sensory-discriminative components, evaluative components, and cognitive-affective components. There are 20 categories in the tool, and these examine (or attempt to measure) mechanical qualities, thermal qualities, location and time.  Gracely (2016), in an editorial piece, compares the McGill to a set of paint colour samples – if pain intensity equals shades of grey, then the other qualities are other coloures – blue, green, red – in shades or tints, so we can mix and match to arrive at a unique understanding of what this pain is “like” for another person.

To begin to understand the MPQ, it’s important to understand how it was developed. Melzack recognised that pain intensity measurement, using a dolimeter (yes, there is such a thing – this is not an endorsement, just to prove it’s there), doesn’t equate with the qualities of pain experienced, nor of the impact of previous experiences. At the time, Melzack and Wall were working on their gate control theory of pain, so it’s useful to remember that this had not yet been published, and specificity theory was holding sway – specificity theory arguing that pain is a “specific modality of cutaneous sensation”, while pattern theory held that the experience reflects the nervous systems ability to “select and abstract” relevant information (Main, 2016).  So Melzack adopted a previous list of 44 words, carried out a literature review, and recorded the words used by his patients. Guided by his own three dimensional model of pain, he generate three groups of descriptors to begin to establish a sort of “quality intensity scale”. These were then whittled down to 78 words that have been used since, and by used I mean probably the most used instrument ever! Except for the VAS.

There are arguments against the MPQ – I’m one who doesn’t find it helpful, and this undoubtedly reflects that I work in a New Zealand context, with people who may not have the language repertoire of those that Melzack drew on. The people I work with don’t understand many of the words (‘Lancinating‘ anyone?), and like many pain measures, the importance or relevance of terms used in this measure are based on expert opinion rather than the views of those who are experiencing pain themselves. This means the measure may not actually tap into aspects of the experience of pain that means a lot to people living with it. Main (2016) also points out that interpreting the MPQ is problematic, and perhaps there are alternative measures that might be more useful in clinical practice. Some of the criticisms include the difficulty we have in separating the “perceptual” aspects of pain from the way pain functions in our lives, and the way we communicate it, and the MPQ doesn’t have any way to factor in the social context, or the motivational aspects of both pain and its communication.

In a letter to the editor of Pain, Okkels, Kyle and Bech (2016) propose that there should be three factors in the measurement – symptom burden (they suggest pain intensity), side effects (or medication – but what if there’s no medication available?), and improved quality of life (WHO-5). But as Sullivan and Ballantyne (2016) point out in their reply – surely the point of treatment is to improve patient’s lives – “we want to know if it is possible for the patient’s life to move forward again. However it is also important that we do not usurp patients’ authority to judge whether their life has improved” (p. 1574). What weighting we give to, for example, pain reduction vs improved quality of life? I concur. Even the MPQ with all its history doesn’t quite reflect the “what it means to me to experience this pain”.

Did it help? Answering this critical question is not easy. Pain measurement is needed for furthering our understanding of pain, to ensure clinical management is effective, and to allow us to compare treatment with treatment. But at this point, I don’t know whether our measures reflect relevant aspects of this common human experience.  Is it time to revisit some of these older measures of pain and disability, and critically appraise them in terms of how well they work from the perspectives of the people living with pain? Does this mean taking some time away from high tech measurement and back to conversations with people?

 

(*pronounced “keh-teh” – Maori word for kitbag, and often used to represent knowledge)

Gracely, R. H. (2016). Pain language and evaluation. Pain, 157(7), 1369-1372.

Main, C. J. (2016). Pain assessment in context: A state of the science review of the mcgill pain questionnaire 40 years on. Pain, 157(7), 1387-1399.

Okkels, N., Kyle, P. R., & Bech, P. (2016). Measuring chronic pain. Pain, 157(7), 1574.

Sullivan, M. D., & Ballantyne, J. (2016). Reply. Pain, 157(7), 1574-1575.

 

What is our goal in pain management?


One of the cool things about having worked in chronic pain management since the mid-1980’s is that I’ve seen a few things come and a few things go.  Some things remain, of course, and the things that seem most long-lived are debates about pain reduction vs living with pain. On one hand, there’s an enormous industry set up to help people reduce their pain experience through pharmacology, injection procedures, surgery, hands-on therapy, movement practice, and novel approaches like brain stimulation and even mirror therapy. On the other hand, there’s a smaller but equally well-established industry established to help people live with their pain, usually involving self-management of some sort and following a cognitive behavioural approach.

The two seem almost incompatible in many respects – why would someone choose to live with pain if their pain can be reduced or alleviated? What are the ethics of not offering pain reduction if it’s available? Why focus on hard work learning to live within the constraints of pain if there’s a way to get rid of it?

I wonder if it’s time to look at the underlying reasons for offering pain management. What is the goal? (BTW occasionally I might write “our” goal – and I do this deliberately because I think there are assumptions made by people who live with pain, and treatment providers, that may not always be explicit).

Why do we offer pain treatments?

Looking beneath the “oh but it’s a good way to earn a living” economic argument, I think some of the reasons we offer pain treatment is a sense of moral concern at seeing people in distress. As a society we’ve cast pain as a “thing” that needs to be fixed, a wrong that must be righted. We have cast ill health and disease as something that should not exist, and we use words like “war” or “battle” when we discuss treatments.  The Hippocratic Oath makes it clear that physicians “must not play at God” yet defining the limits of treatment is a challenge our society has yet to fully resolve.

At the same time as we view pain as an ill that must be removed, underneath the moral argument are a few other reasons – we think it’s wrong to allow someone to suffer. We think it’s wrong that people might not be able to do as they wish. We respect individual agency, the freedom to engage in life activities, to express the self, to participate in life fully and completely. And we think it’s important that, when disease or illness strikes, we offer something to reduce the restrictions imposed on individuals.

What’s wrong with these reasons for offering treatment?

Well, superficially and in the main, nothing. As humans we do have a sense of compassion, the desire to altruistically help others. Whether this is because, as a species, we hope someone will help us if we’re in the same situation, or whether we do it because of some other less selfish reason, I’m not sure. But there are problems with this way of viewing pain as an inevitably negative harmful experience. And I think it has to do with conflating (fusing together) the concepts of pain and suffering.

We offer people some treatments create suffering: I’ve just quickly skimmed a recent paper on using long-acting opioids for chronic noncancer pain where it was found that “prescription of long-acting opioids for chronic noncancer pain, compared with anticonvulsants or cyclic antidepressants, was associated with a significantly increased risk of all-cause mortality, including deaths from causes other than overdose, with a modest absolute risk difference” (Ray, Chung, Murray, Hall & Stein, 2016).

Given the poor response to pharmacological approaches experienced by so many people living with chronic pain (see Turk, Wilson & Cahana, 2011), not to mention “failed” surgery – the rates of persistent postsurgical chronic pain range from 12% (inguinal hernia) to 52% for thoracotomy (Reddi & Curran, 2014) – it surprises me that we often don’t discuss what to do (and when) if our treatments produce pain, or make it worse.

Nonmedical treatments can also be lumped in with these medical approaches – how many years of back-cracking, pulling, pushing, prodding, needling and exercising do people living with pain go through before someone pulls the plug and says “how about learning to live with your pain?”

What’s my goal in pain management?

When I see someone who is experiencing pain, whether it’s persistent or acute, my goal is for them to be able to respond to the demands of their situation with flexibility, and to live a life in which their values can be expressed.

That means no recipe for treatment, because each person is likely to have a whole bunch of different demands, things they’re avoiding, things that limit what they’re OK with doing. Values also differ enormously between people – we might all choose to work, but the reasons for working (and the kind of work we do) is informed by what we think is important. I’m intrigued by new learning, new information, and complexity. Others might be focused on ensuring their family is secure. Others still might be working to have a great social network. All of these values are relevant and  important.

Many of our treatments actually limit how flexibly people can respond to their situation – think of “safe” lifting techniques! And sometimes even the time people take away from living their normal life means their values are not able to be expressed. The thoughts and beliefs instilled by us as treatment providers (and from within our discourse about pain treatment) may also limit flexibility – think about “pain education” where we’ve inadvertently led people to believe that their pain “should” reduce because “know they know about neuroscience”.

At some point in the trajectory of a chronic pain problem, the person experiencing pain might need to ask themselves “Is what I’m doing helping me get closer to what I value, or is it getting in the way of this?” As clinicians we might need to stop for a minute, think of this part of the Hippocratic Oath “I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick”  and begin to talk about overall wellbeing rather than just treating “the problem”.

To alleviate suffering we may not need to eliminate pain – we may instead need to think about how we can help people move in the direction of their values

 

Reddi, D. and N. Curran, Chronic pain after surgery: pathophysiology, risk factors and prevention. Postgraduate Medical Journal, 2014. 90(1062): p. 222-7

Ray, W. A., Chung, C. P., Murray, K. T., Hall, K., & Stein, C. M. (2016). Prescription of long-acting opioids and mortality in patients with chronic noncancer pain. JAMA, 315(22), 2415-2423.

Turk, D. C., Wilson, H. D., & Cahana, A. (2011). Pain 2: Treatment of chronic non-cancer pain. The Lancet, 377(9784), 2226-2235. doi:10.111/j.1468-1331.2010.02999.x

“Them” and “us”


The governing principles and purposes of International Association for the Study of Pain (and thus NZ Pain Society) are clear that “IASP brings together scientists, clinicians, health-care providers, and policymakers to stimulate and support the study of pain and to translate that knowledge into improved pain relief worldwide.”
There is no mention in this purpose of the people who experience pain. I think this is an omission.

Pain is a subjective experience. This means we can only be informed about pain when people communicate about it. So many aspects of pain have not been explored in a great deal of detail: things like gender, the lived experience of “good” outcomes vs “bad” outcomes, the use of labels like “failed back syndrome”, the “what it is like to be” a person receiving types of treatments, even determining whether a treatment is acceptable in the context of the real world – or not.

If we want to reduce the burden of pain within our population, shouldn’t we be incorporating the views of people living with pain? so the aims and priorities of those living with pain are included, increasing public awareness of pain and what it means to counter the prevailing attitudes towards people living with pain?

There is, however, a divide between “us” and “them”. “Us” being privileged to know about pain, to develop research agendas, to study pain and translate into improved pain relief, while “them” are passive recipients of such efforts.  This doesn’t fit with my views of the reducing gap between treatment provider and recipient, or of the relationship of collaboration that must exist between a person wanting help and those giving it. And it doesn’t afford a strong voice to people living with pain who have as valid a view as those who do not live with pain.

Is there room for a person-focused approach in pain research? And can people living with pain have a voice?

I’ve been reading some of the very old medical journals, ones like the New England Journal of Medicine from 1812. In this article, J. G. Coffin expounds on the use of cold bathing saying “For several years past from May to November, I have been in the habit of walking or riding on horseback freely til 12 or 1 o’clock of the day, hastening to the water’s edge, and plunging in with the least possible delay; and in no instance have I regretted the habit, but on the contrary have found it alike grateful and invigorating.” Now I’m not about to suggest we all begin cold bathing, but what I want to point out is the very personal nature of this account.

Compare this with an excerpt from Martel, Finan, Dolman, Subramanian et al (2015) discussing self-reports of medication side effects and pain-related activity interference: “Despite the potential benefits of each of these medications for the management of patients with pain, it is well known that the combination of a wide range of medications may lead to a number of adverse side effects, including nausea, dizziness, headaches, constipation, and weakness. These medication side effects are frequently observed in clinical settings and represent a complex pain management issue.” (p. 1092).

Patients,  not people, are discussed in the latter paper, even though the subject of this study is the experience of people taking medication for their pain. Numbers of side effects. Self-reports of pain intensity, reduced to a 0 – 10 scale. “Negative affect” reduced to numbers.  Interference in three areas of activity rated using the same scale.

While I applaud the need to measure variables of importance, I find it interesting that articles about subjective experiences of people feature far less prominently in our esteemed journals of pain research than those presenting a one-step-removed depersonalised view of what is a human experience.

In recent months I have been reading about the space that occurs between a clinician and patient. Benedetti’s writings on The Patient’s Brain (which, incidentally, also and equally discusses the clinician’s brain) help unpack that special place in which ritualised relationships including power and plea are played out every day. What I draw from Benedetti’s book is that while people seeking treatment appear the supplicants, in fact it is they who determine (to a great degree) whether a treatment will be helpful or not. The meanings ascribed to the interaction are formed by the person seeking help. Clinicians play out a role according to the “rules” of this interaction.

In a treatment setting we are but two humans meeting in a shared space. The quality of that interaction, and indeed the benefit experienced by the recipient of treatment, is strongly influenced not only by that person’s expectations, but also by the degree of empathy expressed by the treatment provider.  As Garden (2008) states “The biomedical approach to medicine all too often overrides concern about patients’ psychological and social experiences of illness” (Garden, 2008, p. 122).  She points out some of the factors that lead to difficulty with empathy in clinical encounters are often about social and cultural issues – too little time, sleep deprivation, a clinical culture that neglects clinician’s personal identity and physical experience (p. 122).

We should also know that downregulating empathy for people in clinical encounters can be a self-care strategy, as Reiss indicates in a brief paper in 2010 (Reiss, 2010). Downregulating the “pain empathy” response involves inhibiting neural circuits such as the somatosensory cortex, insula, anterior cingulate cortex, and periaqueductal gray. Downregulating these areas also “dampen[s] negative arousal in response to the pain of others”. She goes on to say “without emotion regulation skills, constant exposure to others’ pain and distress may be associated with personal distress and burnout” (p. 1605).  However, the harm caused by dehumanising, and unempathic healthcare results in focusing on organs and tests and poorer outcomes, as well as greater burnout, increased substance abuse and more patient complaints (p. 1605).

Cohen, Quintner, Buchanan, Nielson & Guy (2011) writing movingly of the potential role health professionals have in stigmatising those experiencing chronic pain. I wonder if the very way we investigate pain, the scientific model so often used to examine aspects of pain and pain management that works by compartmentalising people into “them” (usually people with pain) and “us” (usually researchers and clinicians) also leads to a sense that “we” are different somehow from people who experience pain. And hence from there to organisations established to study the pain of “them” without actually including “them”.

I wonder how many people working in the field of pain and pain management experience pain. Hopefully ALL of them sorry, US. And that means we need to begin thinking about how easily any one of us could become a person living with pain, and perhaps begin considering how we could work together to shift the societal belief that there is a “them” and “us.

Cohen, Milton, Quintner, John, Buchanan, David, Nielsen, Mandy, & Guy, Lynette. (2011). Stigmatization of patients with chronic pain: The extinction of empathy. Pain Medicine, 12(11), 1637-1643.

Garden, Rebecca. (2009). Expanding clinical empathy: an activist perspective. Journal of General Internal Medicine, 24(1), 122-125.

Martel, Marc O. , Finan, Patrick H. , Dolman, Andrew J. , Subramanian, Subu , Edwards, Robert R. , Wasan, Ajay D. , & Jamison, Robert N. . (2015). Self-reports of medication side effects and pain-related activity interference in patients with chronic pain: a longitudinal cohort study. Pain, 156(6), 1092-1100.

Riess, Helen. (2010). Empathy in medicine–a neurobiological perspective. JAMA, 304(14), 1604-1605. doi: dx.doi.org/10.1001/jama.2010.1455

Some people are ready to change and others are not – James Gordon


The full quote is actually:

“It’s not that some people have willpower and some don’t… It’s that some people are ready to change and others are not.”
― James Gordon

Oh how true is that. And any health professional will tell you that there’s just no point pushing for change when the person isn’t ready for it. So often we encounter people who are unhappy with their lot in life, struggling with this and that, and yet they just don’t make changes that seemingly sit right in front of their faces. It’s SO frustrating!

Or, in my case, it used to be so frustrating – because a few years ago I discovered an approach that revolutionised my practice and made me take another look at my expectations and beliefs about motivation. More about that shortly.

This post arose out of the recent publication of a paper by Sarah Hardcastle and colleagues from the Health Psychology and Behavioural Medicine Research Group at Curtin University in Perth. “Motivating the unmotivated: How can health behavior be changed in those unwilling to change?”

This paper outlines several theoretical approaches that have given health professionals some powerful tools to use when working with people who could change but haven’t.  In order to help people in this space, the authors argue that we really need to understand why it is they don’t have “motivation”. So, what is motivation? Simply put, it’s the desire to do things. And for many of us, we think of it as a “thing” that you either have, or you haven’t. But motivation is a tricky thing – ever been disinclined to go visit someone who’s invited you to dinner, dragged yourself there and then had a fantastic time? Or had one of those ideas that flash through your mind, get all excited about it … but never get around to it? Motivation is a fluid thing and doesn’t always equate to action!

Amotivation, or lacking in motivation, is quite specific to a particular action or set of actions. It may be because a person doesn’t think he or she will be successful if they try. Why bother if you know you’re going to fail? This is about having low self-efficacy, or low confidence and thinking it’s not possible to obtain skills or capabilities to be successful.

Amotivation can also occur if a person thinks it’s going to take more out of them than the rewards from doing it. The costs outweigh the benefits. And it can occur when the effort needed to overcome barriers or to push through feels too much, or the change just doesn’t seem worth it because it’s not that big a deal.

Here’s where I come back to my revolution a few years ago – I found that by using motivational interviewing, I was able to shift the responsibility for making a decision to change back to the person (instead of trying to “make it” happen), but at the same time, recognising the reasons for the person staying where they were. To me, it boils down to respecting that people don’t do dumb stuff for fun. There’s usually very good reasons for them having made a decision, either to make a change, or NOT to make a change. What they’re currently doing works, at least to a certain extent.

Using motivational interviewing, the first and most important thing to learn is to respect the person and take the time to understand the good things they recognise about their current situation. Because there are always some good things about being stuck – it’s easier, for one, than making a change. It’s familiar. It’s worked once or twice. People know what to expect. Change always means disruption somewhere, and that’s not comfortable or easy.

If we look at the reasons I outlined for NOT making a change, and work through them, I think (and so do the authors of this paper!) that there are some things we can do to make change less difficult, and in so doing, build momentum for change.

  1. Lack of self-efficacy – if someone doesn’t think he or she will succeed, why would they even begin? Personally I think this is a big part of “lack of motivation for returning to work” which is something I’ve seen written in way too many clinical reports. If someone doesn’t think they’ll be successful, how could we make the change less challenging? Increase support? Make the steps smaller? Look at other things the person has been successful in? Find out how they’ve made changes successfully in the past and use that?
  2. Not valued highly – or, something else is more valued than this right now. Respecting that there is a time and place for things to be done, and that other things in life can over-ride making changes is both authentic and human. It means that this change isn’t yet important enough – so, how do you build importance? To me, importance is about values and what a person wants in his or her life. There are often discrepancies between what we want and what we’re doing, and sometimes this is because it’s too difficult or messy to think about it. I think part of our job as health professionals of any discipline is to help people consider things that are tough. To reflect on the short and long-term outcomes of carrying on in status quo, and the same if we made a successful change. Things we do because they’re more comfortable in the short-term can be incompatible with what we really want long-term. It’s part of my job to help people think about this. NOT, I hasten to add, to “make” them decide in any particular direction. That’s not my job, I’m there to help people think about how their actions today might affect the future, and let them make their own decisions. At the same time, I can choose to reflect the reality of the long-term effects of today’s actions. That’s being responsible as a health professional.
  3. Feeling the end result isn’t worth it, or that there are too many things in the way – again, to me this feels a lot like addressing self-efficacy. If there are things in the way, or it feels too hard, then part of my job is to help the person find a way that is within their capabilities, and to grab a vision of what it might feel like to have successfully achieved that end result. Asking the person to “look forward” to a few months, years down the track – what would it look like if they made a change that worked? How would this affect what’s important to you? If you decided not to make a change, what would things be like? Would that be what you want?
  4. Habits making it hard to think about changing – It’s easy to over-indulge on chocolate when there’s one of those “treat boxes” in the workplace. It’s easy to go home and stay at home rather than go for a run if you don’t have running shoes and a change of clothes in your car. Environmental triggers where it’s easier NOT to do a healthy thing make it difficult for someone who’s just not even thought about making a change. Employers, healthcare facilities and both local and central government can make it harder for people to do unhealthy things simply by structuring when and where people can access them. So the carpark a little further from the workplace can make it easier to get more exercise each day, banning smoking from healthcare facility grounds makes it harder to get a smoke break, having healthy options in the “treat box” can make it easier to choose something healthy. This set of changes can feel a bit “nanny state”, but they’re effective and useful when it’s those simple little changes that make the difference between living well, or not.

Motivating for health behaviour change starts with building confidence and importance. Maintaining behaviour change involves a lot more – but that’s for another post. In the meantime, I think Atoine de Saint-Exupery had it right when he said:

“Quand tu veux construire un bateau, ne commence pas par rassembler du bois, couper des planches et distribuer du travail, mais reveille au sein des hommes le desir de la mer grande et large.

If you want to build a ship, don’t drum up people together to collect wood and don’t assign them tasks and work, but rather teach them to long for the endless immensity of the sea.” Antoine de Saint-Exupery

Hardcastle, S.J., Hancox, J., Hattar, A., Maxwell-Smith, C., Thøgersen-Ntoumani, C., & Hagger, M.S. (2015). Motivating the unmotivated: How can health behavior be changed in those unwilling to change? Frontiers in Psychology, 6, 835. doi: 10.3389/fpsyg.2015.00835