Quick update from earthquake city

The aftershocks seem to have slowed a little, and they are not as powerful so hopefully things will settle down a bit. We still don’t have water, so we’re having to use our emergency stash (60 litres!) and boil it to wash, do dishes etc. Even when the water comes back on, we’ve been advised to boil the water again because there’s damage to the sewers.
I feel OK in myself, in that I’m not fearful of the quakes (a bit fatalistic really, but there is so little time to react when a quake hits, there seems little point in being afraid – you can’t do anything!), but I am very tired and not sleeping all that well.
I think the difference for people in Christchurch now, compared with the previous two big earthquakes is that the adrenaline rush that was there last time hasn’t been available this time. There’s less energy reserve to draw upon and the daily hassles of dodging potholes and cleaning up liquefaction and working out which shops are still open and where they’ve relocated to – all of that practical ‘stuff’ that is usually there in the background – these things take cognitive effort. Routines and habits make life easier, mean the brain can be freed for more important things. For me anyway, the routines and habits are disrupted and require thinking and planning and time.
I ask myself how are these changes I’m working through any different from the sort of changes in “how to do” that a person with disability needs to make? How often do clinicians forget that doing things “differently” takes mental effort – and in pain management, we’re often asking people to do almost everything in life “differently”. No wonder there are times when people who have limited resource to draw on (maybe fewer social supports, fewer original habits and routines, mental health problems, less flexibility in the ways they are able to view their world) struggle to cope with the demands of both a pain problem (which already makes demands on them) AND our suggestions for change!

I’m off to work shortly, to work with a group of people who have chronic pain and who have been incredibly courageous in wanting to keep going with the last week of their programme despite the earthquake. They were given the choice to stop, to defer the programme and return again, but they chose to stay. That is strength and resilience folks. I am so lucky to work in this field, with the team and patients I work with.

Wobbles in the Quakey Isles

By now, if you’re a regular reader of my blog, you’ll know that I’m from Christchurch, NZ, and yes, we’ve had a few earthquakes recently! I’m happy to report that while we’ve had some more damage to the surrounds of our house, and there are a few more cracks in the ceiling and bricks, we’re pretty well off. No serious damage done except a rather disrupted night!
My nerves are a bit frayed and I keep monitoring any deep rumbling sound or rattle of the windows just in case it’s the beginning of another one – and yes, it’s a bit wearing. I’ll keep blogging but will keep the number of posts down, as I have been, just to reduce some of the (internal) pressure I put on myself to post often!
It’s tempting to say something a bit trite like “we’re all tough here” or something but really, it seems to me there is little I can do to change our situation, much to be grateful for, and more reasons to be positive than not. So if being tough is equal to being occasionally grumpy, tearful for a moment or two, laughing often, taking time out, and finding good things to appreciate, then I suppose I’m being tough! This is life, and life can randomly throw challenges as well as delights. That sounds awfully philosophical, but seriously folks – that’s my way of getting through and being OK.

Opportunity for a conversation

I had a wonderful discussion with another occupational therapist about the profession’s response to the earthquake.  “How”, she asked, “Can occupational therapists from the other end of the country help those in Christchurch?”

To further this discussion, I’ve added a new page to my blog for people to contribute their thoughts about how occupational therapists can aid in the recovery process for people in Christchurch.

Feel free to contribute, comment, say your piece – and even if you’re not an occupational therapist, but you have some thoughts about how occupational therapy as a profession might be able to help, please add your comments too.

Go here for the page…

Friday in Christchurch

Despite the devastation, there are some wonderful sights in Christchurch right now.  This one (above) made me smile today.

And this one was taken in Nelson after we had turned back to return to Christchurch last week.  Cheerful things, sunflowers, and glorious colour on a rather gloomy and very grim day.

Online CALM – Resources for calming the mind and increasing emotional resilience

I found this website today CALM – it’s put together by three lecturers at the University of Auckland, and has a whole series of downloadable MP3’s on methods that will help develop resilience and positivity for dealing with life’s ups and downs. Actually, the whole website can be downloaded and played from a computer off-line, which is great if you’re wanting to access this for your personal use.
The areas covered are Mental Resilience; Managing Stress, Anxiety and Depression; Healthy Relationships; and Finding Meaning in Life.

While each area is dealt with quite briefly, there are loads of worksheets and MP3’s in each area. It’s that part that excites me! The MP3’s cover topics like ‘self hypnosis’ (by Dr Bob Large, Psychiatrist and Pain Specialist from The Auckland Regional Pain Service); Progressive muscle relaxation; Mindful breathing; Developing a coping plan; two on relationships; a whole bunch on religion and meaning in life including Catholic, Anglican, Bhuddist, Hindu; and meaning in life.

This site isn’t developed specifically for pain management – it’s for general life! Well worth a visit on a wet Sunday afternoon.

Friday Funnies – and special places on the net

Things I wish were real…and some that actually are.

Yes, that’s a USB pet rock.  It simply sits. Being a rock.

– if you get the munchies?

An occupational therapists ‘extreme solution’ (please, don’t!)

And special people and places I’ve seen…

Marianna Paulson, aka AuntieStress (on Twitter) – a warm, caring person who shares readily and writes about life as it is – go here for a taste

Research Blogging, edited by Dave Munger, tireless, indefatigable man with humour and passion for getting real research ‘out there’ – go here for the latest research posts

Tony Bridge – for a visual feast, and unafraid to be himself online and share his ups and downs, he comes across as very real – go here for stunning pictures

That’s it for today – I hope your weekend refreshes, enchants and engages your imagination.

Health coach?

I wonder what it would be like to change our focus in pain management – what if we looked to promote wellbeing rather than ‘manage pain’? What would this look like?
Today’s post I want to dream a little – call it me an idealist, but I think if we start with a vision of what might be, and work towards it, we’ll go much further than if we look only to what can be. I’ve been thinking about the concept of health coaching for a while now – I think if I can do with one, I’m surely not the only person!

What I mean by a health coach is someone who spends time finding out what you want to create in your life, then helps you put the things in place to achieve it. I think it’s a bit different from ‘being a therapist’, or ‘treating’ someone, because the focus is on creating the positive rather than overcoming the negative.

I’m not the only person to have thought of this idea! In Australia there is ‘Health Coaching Australia’, and in New Zealand there are several practices where health coaches work – unfortunately, these ones are tied in with naturopathy and personal training rather than an evidence-based approach to living well.

So, what could something like this look like?
Well, coaching is about helping people define a goal and systematically work towards it. A coach can help resolve ambivalence, encourage, crack the whip and generally kick butt when needed. A coach doesn’t define the goal, the person usually knows what he or she wants to achieve, but acknowledges that getting there can be difficult on your own – a coach supplies that definition and urgency to persevere and stay honest!

I’d love to see people with chronic pain view their situation as an opportunity to learn to live well. To infuse their days with the good things that they can have despite chronic pain, and to see the limitations that chronic pain brings as a way to recognise the need to build resilience and flexibility. This doesn’t mean that having chronic pain is a walk in the park – it’s a truly frustrating experience. But the things we do to learn to live with chronic pain are not a lot different from the things we do to live well without chronic pain. We want time with family and friends, good sleep, paced energy through the day, a good diet, an exercise programme that fits our lifestyle, time alone, time to create, fulfilling jobs – sound strange? or sound like what a good life consists of?

It may simply be a change of perspective rather than a whole new approach, but I think I’d rather be cheering on the sidelines than being ‘a therapist’ in an office. I’d rather see people out in the world doing what they love than working out their ‘problems’ and ‘addressing issues’. Problems and issues certainly arise, but I wonder whether they would have that heaviness and emotional drag if we viewed them as obstacles to climb over or zigzag through on our pursuit of the good and healthy, rather than ‘issues’ that need to be dug through.

For some good reading on this idea of health coaching, there are lots of resources here at Health Coaching Australia. This is a paper from 2003 used as a briefing document for health practices in the UK. This document is a great dispeller of myths about men’s health.., and this is a nice summary assessment form if you were going to look at health in general with someone.

What’s different about the health coaching approach? I think it’s the view that the person being coached can decide whether or not to follow the coaching – a coach cares and encourages, but doesn’t actually run the race or play the game, that’s up to the person. What a nice way to view health management!

Some awesome CBT worksheets and resources

If you’re like me, you probably want to be able to put your hands on some easy-to-use worksheets for use with clients.  While I’m happy to make up my own, it’s nice to find some resources on the web – so thanks to therapyworksheets I’m linking to some of the worksheets I like from this blogsite.  These are NOT all pain-related ones, sorry.

First up is Lynn Martin’s CBT worksheet page.  Lynn has a whole raft of professional qualifications, but her original training is as a registered nurse.  Her site also contains a couple of concise summaries on CBT, and links to resources.  To use her worksheets you’ll need to cut and paste (and then probably reformat) into another document – but that’s hardly difficult is it?!

The next is from Specialty Behavioral Health, which has a lot of pdf documents on various mental health problems – including some helpful ones you could use if you were setting up a new practice, such as an intake form, consent form, privacy notices and so on; plus a range of specific CBT forms such as the Daily Mood and Thought Record, and one that I think I probably need: Common procrastination profiles.  I notice that these have been based around student issues such as writing a dissertation, breaking up with a boyfriend and so on, but they could be easily adapted.

Some lovely ‘personal growth’ worksheets are available from Intuitive Life Coach.  Some of these are very simple indeed – but because they’re well designed, they’re easy to use.  One example is the LifeScape Worksheet which is described as  ‘a tool to help you create a certain scenario or experience in your life. The point of this exercise is to draw a specific “picture” of the scenario using descriptive phrases that capture the essence of the experience—the feeling of the scenario as if you were experiencing it right now.’

Psychology Tools is a ‘central repository for materials useful to psychologists and other mental health professionals. The aim of the site is to provide free downloads of copyright-free materials, and also links to copyright materials.’  You can submit your own materials if they’re copyright-free (creative commons) – I haven’t done so yet, but will do.  Nothing here on pain management, but several resources on various disorders and even one on self esteem.  I liked the link to the Wellbeing Wizard – all about wellbeing(!), some nice information on Systems (such as how to draw a genogram), and I was impressed with the resources on mindfulness.

The last one for today is called Living CBT, which is adivision of the Manchester Centre for Cognitive Behaviour Limited. The Centre provides training and consultancy services across the UK at CBT-Centre UK. They have some simple pdf and word document resources including a pain diary, activity diary, and a great set of helpful self statements that are worthwhile copying and plastering all over your own workplace, not to mention for patients!

NEW: (March 2011) I just received an email from James Hardie from Moodjuice, a self help website developed by a team from the NHS Scotland.  This site has both patient and professional areas, lots of resources, and for professionals, a “build your own” resource area.  Excellent stuff, and I’d love to see more of this on the web.

NEW: (April 2014) I’m not sure why I’ve left this site out for so long, truly one of the most comprehensive sites I’ve seen, with a wonderful range of worksheets including case formulation, a self-help CBT book, and loads of patient resources – GET Self Help and Therapy Resources

Pain management: CBT or a CBT perspective?

There is a bit of a misconception about CBT for chronic pain management. Some people think that it consists only of cognitive behavioural therapy as it is used for depression or other mental health problems. And this often means people think mainly of cognitive therapy as conducted by clinical psychologists – meaning that clinicians from other professions can lack confidence to be involved.

I thought today I’d outline the views of one of the ‘founding fathers’ of the cognitive behavioural perspective for chronic pain, Dennis Turk. In a paper by Turk and colleagues Kimberley Swanson from University of Washington School of Medicine, Department of Anesthesiology, Seattle, and Eldon Tunk, Emeritus Professor in the Department of Psychiatry and Behavioural Neurosciences, McMaster University, Ontario, the psychological models used to conceptualize chronic pain—psychodynamic, behavioural (respondent and operant), and cognitive-behavioural are described. They also briefly review treatments based on these models.

One of the main points of this editorial paper is, in their words, ‘to differentiate the cognitive-behavioural perspective from cognitive and behavioural techniques and suggest that the perspective on the role of patients’ beliefs, attitudes, and expectations in the maintenance and exacerbation of symptoms are more important than the specific techniques.’

Distress and wellbeing – two sides of the same coin?

Predictors of psychological distress and well-being in women with chronic musculoskeletal pain: Two sides of the same coin?
Alexa Hubera, Anna Lisa Sumana, Giovanni Biasib, Giancarlo Carlia

This is an interesting article on the concepts of wellbeing and distress. Distress is often considered a key element in whether someone has ‘good quality of life’ (see my post from a day or so ago), but in this article, the relationship between psychological distress and well-being was explored, and the predictors of both in patients with chronic nonmalignant pain are identified.

Why would we be bothered about distress and how is it measured? Distress is not a particularly well-defined concept, but is often referred to in the same breath as ‘eustress’ and ‘distress’ (see this entry in Wikipedia for an exploration of several theories relevant to stress and coping). If its used in this way, it often refers to suffering (which is about negative judgements of a situation or event), and is distinct from depression. Using Loeser’s onion rings model of pain, it’s the emotional judgement of pain that negatively impact on the individual.

In this article, however, the authors refer to two traditions and the impact these traditions have on our ideas about wellbeing. To quote ‘[the] hedonic approach focuses on happiness, while the eudaimonic approach defines well-being in terms of the degree to which a person is fully functioning, which may or may not be accompanied by feeling good.’
This reminds me of the traditional WHO definition of health – which is not simply the absence of disease!

One of the reasons I was drawn to this study was the statement by the authors that ‘To date, few studies on well-being in patients suffering from chronic pain have been published’. (Of course I’d argue that experiencing chronic pain may be mandatory, but ‘suffering’ is optional!) This is precisely the point I’ve been trying to make for some time in that most of our knowledge about people experiencing chronic pain is drawn from people who are seeking treatment. People who live well despite having chronic pain are not studied often and hence we know relatively little about them.

So, getting down to the nuts and bolts of this study: 69 women recruited from a University Hospital Rheumatology centre. The majority of them met criteria for fibromyalgia, while the remainder had widespread pain, and many of them also experienced other conditions associated with central sensitisation syndrome (e.g. psoriasis, irritable bowel syndrome, headache, fatigue).
They all completed a raft of measures, but the ones I want to focus on are those assessing distress:
The Symptom Check List-90 (SCL-90) measures psychiatric symptoms and psychological distress and has been used often in this type of research.
The State–Trait Anxiety Inventory Form Y (STAI-Y) consists of two scales measuring state (STAT-Y1) and trait anxiety (STAT-Y2), respectively. It’s been used in many studies of anxiety in different patient and community groups.

The Multidimensional Affect and Pain Survey (MAPS)was used to measure pain-related emotional suffering and well-being. It consists of 101 descriptors within 30 clusters, grouped into three scales.
1. The Somatosensory Pain scale measures somatosensory pain sensations, and its results weren’t considered in this study.
2. The Emotional Pain scale (EP) measures pain-related emotional suffering within eight areas: Physical Illness, Depressed Mood, Self-Blame, Anger, Anxiety, Fear, Apathy, and Fatigue.
3. The Well-Being scale (WB) measures aspects of wellbeing in five clusters. The first two clusters—Mentally Engaged (e.g.,“interested”) and Physically Active (e.g., “vigorous”)— measure healthy activities and follow the eudaimonic tradition (which defines well-being in terms of functioning, not happiness).
The third and fourth clusters—Affiliative Feelings (e.g.,“sympathetic”) and Positive Affect (e.g., “happy”)—measure happy thoughts and really within the hedonic tradition. The fifth cluster, Treatable Illness, measures to what extent the patient believes that his/her illness is “curable” or “manageable” and represents a separate dimension of well-being.

(Just a comment – I’m not sure of the relationship between this measure and measures of acceptance such as those being studied by McCracken and others).
The other variables included in this study were ‘general epidemiological–anamnestic questionnaire, six measures of physical symptoms (tender point count, pain area, pain intensity, fatigue, stiffness, and physical disability).

Now for some statistics – not particularly challenging ones, so don’t panic!
Pearson correlation coefficients were used to assess the relationships between measures of well-being and psychological distress, applying Bonferroni adjusted α levels.

These showed only three physical symptoms—pain intensity (VAS), number of positive tender points, and physical disability (FIQ)— showed meaningful correlations with psychological distress and/or well-being.

A hierarchical multiple regression analysis was carried out to separately predict each of the six measures of well-being (WB-4 and each of the five WB clusters) and three measures of psychological distress (MAPS EP, STAI-Y2, and SCL-90 GSI).  ‘Predictors were entered in the following order in five steps: (a) age; (b) pain duration (i.e., time passed since the onset of pain symptoms); (c) pain intensity; (d) number of positive tender points; and (e) physical disability.‘ Just so you know, several of these were mathematically transformed to make the stats assumptions work (which may affect the rigour of the results), but at least they told you about it!

Ok, results.
Well, almost half the participants reached the cut-off score for trait anxiety, and many of them also reached the score for high distress.  They sound fairly like the people that get referred to Burwood Pain Management Centre.

In terms of psychological distress, higher age and more physical disability emerged as the two most important predictors of psychological distress, each making unique contributions.

‘Both Pearson correlations (and multiple regression demonstrated that wellbeing (as measured by WB-4) was significantly predicted from low physical disability alone, and was independent of age, pain duration, pain intensity, and tender point count.’

What does this actually mean?
The results really show that the relationship between psychological distress and pain-related symptoms, may be mediated by the patient’s limitations in the capacity to perform daily household chores (ie disability).

We know that disability is influenced by a whole range of factors including the responses of significant others – and the cognitive interpretation of the meaning of those limitations, such as the disparity between what the person believes is expected of them as compared with what they believe they are capable of.  It’s not simply about pain intensity.

Wellbeing, on the other hand, decreased with higher disability but, in contrast to psychological distress, was independent of age, pain intensity, and tender point count.

Now the finding that well-being was independent of pain intensity is an important result of this study.

Yesterday I quoted from Katz where it was assumed that if pain intensity alone was reduced, ‘quality of life’ would improve. I wouldn’t want to equate ‘quality of life’ with ‘wellbeing’ – but the dimensions are similar, and suggest that it’s simply not enough to reduce pain without simultaneously addressing other issues that are important to the individual.

As the authors state ‘Our findings suggest that, in patients with chronic musculoskeletal pain, well-being is related to aspects of physical disability that are not directly linked with pain. The results are in line with the literature demonstrating that the negative impact of chronic pain on physical functioning and work status is moderated by cognitive and psychosocial factors, such as pain catastrophizing and pain-related fear of movement.’

They add ‘Results are consistent with the view that pain behavior, rather than pain per se, should be the target of treatment’. Not news to many of us, but perhaps to those clinicians with a somewhat simplistic (or perhaps simply a biomedical) viewpoint, it may be surprising.

I’m also keen to support their contention that psychological wellbeing should be measured as an outcome quite distinct from a reduction in psychological distress. It’s a new concept for health care – to think that along with ways to reduce distress, clinicians could also consider ways to enhance wellbeing – and that this can occur in the absence of a focus on pain reduction.

It makes me think that the emerging field of positive psychology is something that pain management clinicians could well start to view more seriously. My post from the other day on counting blessings comes to mind. And for those of us working in the field for the long term – it might make our work just a little lighter and more fun!

HUBER, A., SUMAN, A., BIASI, G., CARLI, G. (2008). Predictors of psychological distress and well-being in women with chronic musculoskeletal pain: Two sides of the same coin?. Journal of Psychosomatic Research, 64(2), 169-175. DOI: 10.1016/j.jpsychores.2007.09.005