values

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

What does using a biopsychosocial framework mean in practice?


A good friend of mine told me that during her training (as a physiotherapist), psychosocial factors were “what you blame when your treatment doesn’t work”. It’s something I’ve heard more than once. I’ve also been asked many times “…but are you sure you’re not doing something outside your scope of practice?” when I talk about using cognitive behavioural principles and ACT (Acceptance and Commitment Therapy) and other psychological strategies. And some of you might have seen earlier posts of mine where I ask “How social is your biopsychosocial model?”

Today’s medical students are trained in using a biopsychosocial framework in their undergraduate years. They leave medical school, begin their hospital and advanced training, and I guess I wouldn’t be alone in asking “what happened to the psychosocial?” when we see them working.

So today’s post is a bit of a reflection and a musing on what I think using a BPS approach might mean in pain practice.

BPS is, I think, less of a “model” than a way of thinking. Thinking that is based on a systems approach – every factor affects and is affected by every other factor. In fact, Engel, the originator of this way of viewing human health, was strongly influenced by general systems theory which was developed by Ludwig von Bertalanffy, a biologist who lived between 1901 – 1972. General systems theory was a model describing processes thought to be common in many different fields of knowledge. General systems theory is based on these five beliefs:

(1)  There is a general tendency towards integration in the various sciences, natural and social.

(2)  Such integration seems to be centred in a general theory of systems.

(3)  Such theory may be an important means of aiming at exact theory in the nonphysical fields of science.

(4)  Developing unifying principles running ‘vertically’ through the universe of the individual sciences, this theory brings us nearer to the goal of the unity of science.

(5)  This can lead to a much-needed integration in scientific education.

Engel then applied this to a model of the influences on human health. At the time he wrote his seminal article (Engel, 1977), psychiatrists were being challenged by reductionism on the one hand, particularly around approaches to mental health – the distinction between “diseases” where biological causal factors are influential, such as neurological disorders, and “problems of living” such as alcoholism, where the relevance of biology was, at the time, hotly debated; and concern that psychiatrists might lose ground to nonmedical practitioners such as psychologists. It’s an argument that continues today: should, for example, nonspecific low back pain be the domain of medical practitioners or should physiotherapists, occupational therapists, psychologists and others pick up primary responsibility for its management? (For a very interesting discussion of socio-political debates about this, read Wilson, N., Pope, C., Roberts, L., & Crouch, R. (2014). Governing healthcare: Finding meaning in a clinical practice guideline for the management of non-specific low back pain. Social Science & Medicine, 102(0), 138-145. doi: http://dx.doi.org/10.1016/j.socscimed.2013.11.055)

Back to the story. The broad BPS “model” can’t be tested, and to some, was never intended to be a “scientific” model but rather a discussion tool. A way of shaping a dialogue between the person seeking help, and the clinician wanting to understand what was influencing how and why this person was presenting in this way at this time. I like to think of it as a way to remember that the person seeing you is a person-in-context.

We can argue the toss about exactly which factors belong in which “bit” of a biopsychosocial approach, but broadly speaking, we want to understand biological influences on health. Some of these are genetic (a bit hard to investigate for most of us), some of these are environmental (rickets? Vit D deficiency?), some are other organisms (M. leprae and M. lepromatosis? – Leprosy to you and me). Some are associated with what people do – tripping, jumping off things; while some are associated with what people don’t do – manage diabetes, exercise. The bio part is far more readily assessed and addressed than the other messy bits and pieces, so I won’t deal with that any further.

The psychosocial, on the other hand, is messy. It’s muddled and hard to measure and changes over time and geography and culture.

To me, it means remembering that when two people get together, it’s not just about the words we use, it’s about what we both bring to the setting in terms of experience, habits, expectations, vulnerabilities. It’s about where we meet. It’s about the purpose of meeting. It’s about recognising that everything we say and do is imbued with meaning – but it’s also about not necessarily knowing what we know, or what we don’t know.

So if I’m practicing in a biopsychosocial framework, I’m going to have to know a great deal about myself and my assumptions, my attitudes, habits, how others see me, and even what I don’t know. And the same applies to my knowledge about the person I’m seeing – only because I’m usually the “treatment provider”, I need to shape my conversation so that it’s OK for that person to tell me about this stuff, and this means knowing a bit about how people tick. I especially need to know how to hear what the person coming to me is saying – and not saying.

I see much that is called “psychological” as being about how we communicate and what we know about helping people change behaviour. I’m not “doing psychology” when I teach my child how to tie shoelaces, yet I’m using psychological techniques – modeling, reinforcement, verbal instructions and so on. Likewise when I’m helping someone feel OK about driving their car when they have back pain, I’m using psychological techniques such as verbal instruction, grading the difficulty, encouraging, supporting and so on. To suggest we can’t use psychological techniques to enable normal function is unthinkable.

Using CBT or ACT or motivation interviewing simply means refining my interpersonal skills so that I can optimise the chances that the person feels heard, can understand what I’m on about, and begins to feel OK about taking steps towards the life they want and being themselves. It’s about learning ways of explaining things, learning how to show that I’m listening, learning about the right level of support and challenge that will enhance the chances of success. Most people who live with chronic pain probably don’t need to see a psychologist – they need someone to help them make sense of pain, to show they’re there as they find their way through, and celebrate when they’re doing what’s important in their lives. I think all health professionals should be doing this.

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

Not your usual New Year post


Everyone does it at this time of year: you know it, the “best of” or “10 of my favourite” or “looking back over the year” or any of the other variants. Or perhaps “Goals for 2015”.

I’m not going to. Not because I don’t think there’s anything worth sharing from last year, but because I’m trying to look at life differently for a while. You’ll have spotted the theme in my posts on goals and goal-setting recently – I’m not a great fan of setting goals although I’ve personally set goals most New Year Days throughout my life. But I’ve decided that maybe it’s not such a good thing any more, and here’s why.

I think I pointed out that some people treat goal setting in therapy as a sort of “to-do” list. Tick all the goals and voila! therapy is complete. You’re now perfect. Or at least, you’re ready to be discharged. Of course it’s not like that really, as most outcome studies show. People make quite large changes in the first couple of weeks of therapy, then plateau, then slowly but inevitably, move back to how things were before all the fuss began. I could cite you numerous studies across many different fields of rehabilitation and they’ll pretty much show the same thing. Yes, people are better off than before they came to therapy, but overall change is quite slight.

What, I wondered, would happen if we treated this as normal and part of life? What if we saw therapy as providing only a short-term boost? Would it all be worth it?

And I have thought a lot about the “what it is like” to have achieved goals. So my goal this last year has been a very long time one of completing my PhD. I look back on the process as being one of incredible learning, most of it alone, yet supported by so many people. By taking nearly 7 years to chip away at it, the thesis has become part of me, I’ve developed habits and practices that I find very hard to stop. They’ve been integrated so that I don’t think too much about why I look up a series of references, scan the abstract, view the results, then poke about in the methods section and the stats and finally look at the discussion – when it’s the discussion that so many people think is the best part! This, and asking to see the evidence, and see more than a single study, and wanting verification – these habits have become ingrained.

So a goal, PhD done, I can tick off my list. But I’m still doing the things I did as part of my goal. How then, can I have “completed” it?!

You see, I think goals are over-rated. I think we sometimes look at goals and think that if we achieve X we’ll be satisfied. I don’t think this actually happens. Instead, what I think happens is we develop some habits, and these habits embody what is important to us. So, for example, if we think cleanliness is important, we might set a goal of “having no fillings this year”, but to achieve it we need to make sure we clean our teeth, floss and see a dentist. But the habits of cleaning teeth, flossing and seeing a dentist are the actions we need to take to achieve the goal of no fillings. And these habits or actions are how we show that we think cleanliness is important.  And they get ingrained so we actually live our values.

The problem with goals is that things can get in the way of their achievement. If my goal is to save $2000 for a trip away, any number of habits will help this happen. And the value of saving is in that delayed gratification and all the small habits and actions that make putting money aside something that I do. But in the end, if my car breaks down, or a child needs money, or I have other important things to do with that money I won’t have achieved the goal. Yes I might have saved the money, but I don’t get to do the trip. If the bank’s funds are embezzled, I don’t get the money or the trip. If the air fares increase, I don’t get the trip. But I will have been living a whole series of actions that demonstrate an important value I have: I’ll have learned about delayed gratification, learning I can wait, learning that I don’t need to buy a coffee every day. And these small actions are how I live my life every day, rather than that single trip away that I might have had. Because life really is about these small everyday things we do.

So… setting goals isn’t my priority this year. My priority has been to review my values. What really IS important to me. And these are what I came up with:

  • balance in life – adequate rest, fun, excitement, alone time, intellectual stimulation, conversation, peace, creative time
  • learning – how I do anything is how I do everything
  • beauty and appreciation – natural, human-made, flavours, colours, tones, textures, complexity, simplicity

Only three. Because I think that’s quite enough.

And my actions – they’re the important part of this. What I do each day, all those small acts, they’re the things that count towards living my life, or just ticking the boxes.

If you’re a pain clinician, what little actions do you do to live the values you hold?

Goals? I loathe them: What to do instead


I dislike that acronym “SMART” goals. I can never decide whether it’s meant to mean “Specific, measurable, achievable, realistic and time-bound” or “specific, manageable, active, realistic and timed” And if it’s either of those, what’s the difference between achievable and realistic? Or is it meant to be “relevant”?

In previous posts I’ve established good reasons to have a focus for therapy. Unless the focus is something valued by the client, it’s either unlikely to get done or it’s not their goal and they’re going along with it to keep you happy. Goals, targets or focus are useful, and the logic goes that unless you have them you won’t know where you’re going or when you’ve got there.

I’m not going to argue against the idea of having a focus to therapy. I just think there are risks in having goals, like some sort of checklist that says “If you achieve this, you’re all good”.

Seriously, that doesn’t work in real life. That’s the same kind of logic that says “if I just buy enough things I’ll be happy”, “if I just earn a bit more I’ll be happy”. While there’s a bottom line below which it’s hard to think beyond survival, above that line, having stuff, and even doing things as an end in themselves doesn’t fulfill for long.

What gives forward momentum, enrichment, fulfillment and can’t be ticked off like some shopping list is recognising that life is actually a whole series of actions and events that, when we think back on them, make up a good life. The richer events and experiences and actions feel good and fulfilling. The empty routine and humdrum things feel deadly dull and empty.

When I think about the purpose of therapy my focus is helping people to live the kind of life they value, doing the things they believe are important. Given I don’t want to be a long-term feature in a client’s life (for all I love them, I’d rather they were doing it themselves), my focus is on helping them work out what makes a rich, fulfilled life they can look back on and feel satisfied. My job is to help them develop skills and strategies to carry out the actions needed to live a life aligned with what they value.

Let me unpack this a little.

Many people I see place value on being a good parent, a loving partner, a reliable employee. When I see them, their pain has interfered with doing the things they believe demonstrate “being a good parent” or “being reliable”. Pain has moved in to their lives, and come and sat on their laps right in front of their face so that all they can see is pain.  If I ask someone in this state to “set goals” they laugh, rather sarcastically sometimes, and say they don’t have goals, they can’t think of anything and what’s the point anyway. Perhaps not in those words, but the meaning is clear.

Instead, I ask them “what would you be doing if your pain was less of a problem for you?” Sometimes I’ll even hand over a plastic fairy wand I have, and suggest they dream a little. It’s then that the passion takes over – they’ll say “I’d be out working, having fun with my friends, caring for my family” – and the list goes on! If I stopped there, though, I’d be holding a tantalising dream just out of reach, which is cruel, so I don’t. Instead I ask why these things are important.

That’s how I find out that “family is everything”, “I just love creating”, “I need my friends”.

Then I switch tack for a moment and ask them “How well is what you’re doing to deal with your pain right now working to help you be the kind of person for whom family is everything? How well is what you’re doing with you pain helping you create?”

The reason for this tactic is to help generate what Acceptance and Commitment therapists (ACT) call “creative hopelessness“. Because motivation to change comes from inside – that it’s important enough, and the person is confident that change can happen.

I then suggest two things: 

  1. Is keeping pain happy more important than family ?(and yes, I know I’m personalising and objectifying pain here, and yes it’s an experience not a thing, but it works OK!)
  2. What would happen if you made a little room for pain to be there while you’re doing things that contribute to you being the kind of parent you want to be?

What I mean by this last statement is that pain can interfere with doing that things that help you feel you’re being a good parent. And that can lead to either completely abandoning those activities, or doing them while clutching resentfully to “the pain that interferes”. What if you attended to the value or importance of being the kind of person who is a good parent instead of focusing on the irritation, frustration and anger of having to bring pain along for the ride?

  • For many people, the things they believe contribute to “being a good parent” far exceed what they can currently achieve. So they give up and get demoralised. They both have their pain AND they don’t manage the very things they most value.

Now it’s here that I could begin to “set goals” and suggest we work towards them using all the traditional elements of goal setting. And that probably has excellent value. But here’s the catch: often we hold very strong internal rules about how these things should be done so that unless we can do them exactly the way we think they should be done, we’re not satisfied. And for many people this fails to recognise that as time goes on, life too goes on, and we change the way we do things to accommodate new habits or capabilities. So I try to begin a process of developing flexibility – and using the values a person identifies as a compass rather than a checklist.

What would happen if we thought a little about the range of things people might do to convey “being a good parent”? Maybe it would mean going to the children’s sports games and being a spectator. Maybe it would mean making lunches, helping to do homework. Maybe it would include listening while a kid tells you about his or her day. Many of these things can be done with pain present. Many might require altering how they’re done to accommodate having pain present but provided that they express the underlying value of being a good parent, can be fulfilling.

What’s important is less about the what a person does, and a whole lot more about why and how they do it.  When “being a good parent” becomes the direction we live (because we can never tick the box that says “being a good parent” is complete), then we focus on why and how we do it. Attention goes away from “but pain stops me”, and towards discovering all the ways “being a good parent” can be lived.

Often it’s through doing this that people seek new coping strategies so they can extend what they do. People may “set goals” or future actions they want to take but instead of feeling frustrated and dissatisfied, they begin to to take actions that bring them closer and closer to living the life they want to live. And that, my friends, is what I think “goal setting” is about.

This festive season is a good time to consider what’s important in your life. What actions are you taking to live a value-filled life?

Stepping out of the glue: How to generate goals


Chronic pain has been called one of the “most powerful and insidious disruptors” of routine, habit and wellbeing (Karoly, Okun, Enders & Tennen, 2014).  When a person experiences pain, a whole range of mechanisms come into play and work together to use thinking and processing space, and especially those areas we use when we’re developing and achieving goals.  When people are first trying to make sense of their situation, they can find it hard to think about future goals and plans, and instead focus on trying to solve the problem of pain – many people call this time like being in limbo (McGowan, Luker, Creed & Chew-Graham, 2007).

It’s not surprising, then, that when clinicians begin to work with someone who has had pain for a very long time, it can be very difficult for them to think of a “goal”. After all, not everyone sets goals anyway (I heard somewhere that it’s about 3% of people – but I can’t find the research to support it). But in pain management, funders often ask clinicians to work with the client to “set goals” for therapy from the first day as a way to ensure a client-centred programme, increase motivation, and monitor outcomes. This can be a problem in a couple of ways: first of all, if the person doesn’t have goals because they’ve been in “limbo land” for a long time, and feel pretty demoralised or their goal relates to “getting rid of the pain”; secondly, if the person has vague ideas that are difficult to set into the typical “SMART” formula (incidentally, I really don’t like that acronym!); thirdly, if the person doesn’t have strong ideas about what they want from therapy, the clinician can set the goals for them, and perhaps not those the client is really all that interested in; and finally, it’s hard to set goals without having spent some time listening to and collaborating with the client.

Pain can be experienced as a major obstacle to motivation for setting goals. Negative mood associated with pain can reduce motivation to think ahead, to dream. Morning pain in particular can make it more difficult to want to do things, unless those activities are important, there are relatively structured ways to pursue them, and they don’t need much planning.  This can influence whether a person gets out of bed to go to work, or the gym, or take the kids to school. In a daily diary study, Karoly, Okun, Mooris, Enders and Tennen (2014) found that people with relatively high overall pain over a two-week period, but not necessarily just in the morning, and who have chosen to stay working, often also carry out their “lifestyle” goals in the afternoon. They suggest this could be because goals that are further out in time, and the positive feelings associated with achieving work goals keep them motivated. But they also found that even then, on the days people had more than their usual pain in the morning, they were less inclined to do as much.

The implication of this finding by Karoly and colleagues is that people who experience a “high pain” morning might need some reminders of the pleasure they get when they achieve goals – perhaps to pay attending to people and places that support their goal achievement. Helping people develop goal planning skills might also be useful – do the thinking when you’re feeling a bit more positive and can see beyond “now”, then when pain is higher, the cognitive demanding work is already done and the reminders help to generate positive emotions to encourage doing them.

OK, so we know some ways of helping people keep motivated, but what do we do to help people set them in the first place?

People are motivated by both push and pull factors. We want to move towards things we experience as good, and away from things we don’t enjoy. When pain is present, not only does it become hard to think straight, it doesn’t feel like it will ever change. So we need to help people dream a little. One way I do this is ask “What would you be doing if pain wasn’t such a problem for you?” Note that I’m not saying pain isn’t there – but that it’s less of a problem. Sometimes I’ll use a plastic magic wand and hand it to the person, asking them to dream a little. Other times I’ll add in “What gives you joy and pleasure? What makes you lose your sense of time and place? What gives you a sense of satisfaction when it’s done?”

These questions begin to identify activities in which a person might experience “flow” – Mihaly Czikszentmihalyi.

Another way is to ask the person what they need to, or want to do, perhaps using the occupational therapy broad groups of “productivity/work”, “leisure/fun”, and “self care” as prompts.

I’ve also found that by asking “what’s important in your life” can be a good way to generate personal goals. Importance indicates that the person places value on it. Values are important and lasting beliefs or ideals shared by people about what is good or bad and desirable or undesirable. Values underpin ACT (Acceptance and Commitment Therapy), because instead of setting goals, which can be achieved, values are like a compass – things we do (actions) allow us to move closer towards important values, and we never completely achieve them. They’re directional and aspirational, and allow us to do difficult things that have short-term negative consequences, just so we can move towards a better long-term consequence (van Huet, Innes & Stancliffe, 2013).

How can you use this in therapy?

Well, if a person really values family, and being a good Dad, anything that Dad does to enable him to be a better Dad will be motivational. So you can ask “What could you do today that would take you one step closer to being a great Dad?” And use whatever that might be as the foundation for a goal. Then you can go on and use all the other great goal-setting strategies like specific, measurable, achievable, relevant, and so on.

This doesn’t mean that doing that thing will be easy – far from it! But it will make achieving it more relevant, powerful and motivating. Working with the challenges is why you are a therapist.

 

Karoly, Paul, Okun, Morris A., Enders, Craig, & Tennen, Howard. (2014). Effects of Pain Intensity on Goal Schemas and Goal Pursuit: A Daily Diary Study. Health Psychology, 33(9), 968-976.

McGowan, Linda, Luker, Karen, Creed, Francis, & Chew-Graham, Carolyn A. (2007). ‘How do you explain a pain that can’t be seen?’: The narratives of women with chronic pelvic pain and their disengagement with the diagnostic cycle. British Journal of Health Psychology, 12(2), 261-274.

van Huet, Helen, Innes, Ev, & Stancliffe, Roger. (2013). Occupational therapists perspectives of factors influencing chronic pain management. Australian Occupational Therapy Journal, 60(1), 56-65.

Which comes first: Doing or knowing?


ResearchBlogging.orgReceived wisdom in cognitive behavioural therapy says that to change behaviour, a person must first change his or her thinking.  This has created a tension between those clinicians who emphasise the cognitive aspects of pain management – and those who focus on helping people with pain do more.  Should we educate and target cognitions, particularly those sticky core beliefs – or can we use behaviour change as a way to help the person make gains?

The answer is, as you’d have guessed, not black and white.  In fact, as several authors and researchers have pointed out (see the references below for just two), not only is the cognitive behavioural approach to chronic pain management a mixed bag of strategies, there is very little information on the process of change that occurs during treatment.

Here’s what I’ve seen clinically – while some people are ready to change, others are not.  I need to work with this second group using motivational interviewing approaches to help them identify their own reasons for doing things differently.

This might mean creating a sense of dilemma – identifying where they are now in terms of goals and satisfaction with life, and creating awareness both of the possibility that life might be different, and what that might look like.  This helps people recognise their “stuckness” and creates momentum for change.  From there, it’s far easier to help them develop goals and start to problem-solve what needs to happen to reach them.

Another group of people are those who are relatively inflexible in their thinking and behaviour – they’re stuck not because of a dilemma, but because they’re continuing to use strategies that have worked for them in the past, but are not working now.  It’s like they have trouble working out another way of approaching problems.

A good example of this is a man who has always been fit and before his pain began was a representative sportsman. His approach was always to do more than what was required. He was stuck because doing this when he had pain created a “boom and bust” approach to activity.   For this kind of person, I like to use what Steven Hayes (ACT) likes to call “creative hopelessness” – pointing out that it’s not the methods the person is using, but their purpose. I use experiential methods to do this – gettng the person to monitor what has happened over the week, and asking him to establish what he believes: his mind and what it tells him? or his experience and whether it works.

Cognitive change doesn’t necessarily occur before behaviour change
It’s strange, but true, that despite our best efforts, twelve months after people have completed a pain management programme, few are still using the strategies we help them develop.  While some are goal setting, or using relaxation, or exercising, or even checking in with their thinking – the majority are simply getting on with life (Curran, Williams  & Potts,  2009 – doi: 10.1016/j.pain.2005.09.004). And even more strange – people who start making behavioural changes early in a pain management programme seem to do best, while those who actually complete between-session activities also seem to do best (Heapy, Otis, Marcus, et al., 2005).

Persuasion, challenging core beliefs, and education have their place – for the right reasons, at the right time, for the right person – but they don’t alter the fundamental issue alone. 

 What is that issue? It’s about an attitude shift towards “sitting with” uncomfortable thoughts and sensations, and working towards valued goals despite those thoughts and sensations.  It’s about a spirit of gentleness and willingness to recognise those thoughts and sensations as the mind’s way of solving problems – and at the same time, accepting that it’s entirely possible to do what is important despite the presence of these thoughts and sensations.

Morley, S., & Keefe, F. (2007). Getting a handle on process and change in CBT for chronic pain Pain, 127 (3), 197-198 DOI: 10.1016/j.pain.2006.10.025
Morley, S. (2004). Process and change in cognitive behaviour therapy for chronic pain Pain, 109 (3), 205-206 DOI: 10.1016/j.pain.2004.02.008

Curran, C., Williams, A. C. d. C., & Potts, H. W. W. (2009). Cognitive-behavioral therapy for persistent pain: Does adherence after treatment affect outcome? European Journal of Pain, 13(2), 178-188.