Pain management strategy worksheet and activity

It’s been a while since I directly posted on practical pain management strategies that can be used as part of activity.  A while ago I developed an activity to use with our pain management programme that involves identifying the skills you might use during three common activities.  I’ve uploaded it here for you to use. Be aware that the photographs are from Google images, so are both of variable quality and some may be copyright.

The way you can use this activity is to ask the person to match the title to the definition of the coping strategy (and yes, there are a lot of debates about the definitions so they are by no means definitive!).  You could ask the person to talk you through the strategies he or she uses, or you could use it during assessment as a means of identifying coping resources the person already has, or could develop.  The three common activities (grocery shopping, going out to a restaurant or bar, gardening) were selected because these three are the sort of things people describe as being difficult and often avoided or carried out with difficulty. (more…)

The Pain Survival Guide: how to reclaim your life

For my final (for now) review of self-help workbooks, I’ve chosen one written by one of the most influential researchers and clinicians in pain management, The Pain Survival Guide: how to reclaim your life, written by Dennis Turk and Frits Winter. It’s also not published by New Harbinger, but instead by the authoritative American Psychological Association.

This is a very readable book and its smaller format (than most of the other workbooks I’ve reviewed) makes it a little easier to carry and keep close than many. Despite this, it packs a lot into its over 200 pages, and it certainly contains the majority of the topics that you would expect in a self help book.  It’s broken into ten ‘lessons’ or chapters, designed to be read and followed on a weekly basis. Each chapter focuses on a single concept but refers back to previous chapters and activities, and it provides many ‘learning activities’ to help tailor the approach to the individual.

It has many self-learning worksheets that help the reader to learn more about how the concept being discussed applies personally, and although they are not as expansive in terms of room to write, they are relevant and clear.

Chapters include topics such as:
1. the need to become your own pain management expert
2. activity, rest and pacing
3. learning to relax
4. ways to combat fatigue
5. don’t let pain ruin relationships
6. changing behaviour
7. changing thoughts and feelings
8. gaining self confidence
9. putting it all together
10. maintenance and setback planning

Again, like the workbook I looked at yesterday, it assumes that people reading it are ‘ready’ for action – so no discussion about readiness for change. However, it does emphasise the need to integrate not only the pain management strategies into life, but changing goals and working with others to help return from ‘patient’ to ‘person’.

Aspects I liked about this book – it’s simple, but quite comprehensive. The writing style is easy to read (although probably more difficult than many of our clients could manage), and it doesn’t use too many ‘americanisms’ or jargon-filled sentences, so it’s palatable to New Zealanders! I’m very familiar with the approaches suggested through the book, also the order in which the chapters are presented, in which coping strategies and activity planning are provided first, then behaviours and thoughts are considered later. I also liked the emphasis on relationships and fatigue which are often neglected in this type of book.

Aspects that I didn’t think were so good – as I’ve said before, and will say again, lots of words make it difficult for the people I see to use a book like this without support from a health professional. It’s not as spaced out as some of the other books, so could be a little more difficult to use. It does cover a lot of information, so it can be once-over-lightly in some senses.

In summary – this is a good, sound self help workbook that has a behavioural emphasis that some workbooks don’t have, and a focus on the ‘real world’ which includes sleep, relationships and even having fun!

I like the readable style, and for me single chapters can be stand-alone for some clients (especially the activity planning one!). I’d see it as a book to keep on your desk, perhaps available for loan, and definitely as a support manual for anyone who is participating in an Activity Focused Programme with therapist input.

The major lack in all the workbooks I’ve reviewed is absolutely no attention to the impact of pain on work, and no discussion of how you might use the skills in a workplace where working despite fluctuations of pain is essential. Maybe this lack is an opportunity for someone to develop a workbook that does address this area?

The Pain Survival Guide
How to Reclaim Your Life
By Dennis C. Turk, Frits Winter
Format: Paperback, 203 pages
Published In: United States, September 2005
Publisher: American Psychological Association (APA)
ISBN: 1591470498
EAN: 9781591470496

Managing chronic pain: A CBT approach

Scintillating title, but accurate! This workbook is a skinny one (just 83 pages), and it’s not from New Harbinger Publications! It’s actually from the esteemed Oxford University Press, and is one of quite a few self-help books that this publisher produces in the series ‘Treatments that work’. Written by John Otis, who is an Associate Professor of Psychology and Psychiatry at Boston University, this book has to be the leanest and simplest version of all the workbooks I’ve seen. It’s also the only one I’ve found so far that has an accompanying therapist manual, which is handy – however, for the cost-per-page, this has to be the most expensive one of the workbooks I’ve found too!

The chapters in this workbook include:
1. Education on chronic pain
2. Theories of pain and diaphragmatic breathing
3. Progressive muscle relaxation and visual imagery
4. Automatic thoughts and pain
5. Cognitive restructuring
6. Stress management
7. Time-based pacing
8. Pleasant activity scheduling
9. Anger management
10. Sleep hygiene
11. Relapse prevention

So you can see, it covers the majority of fundamental self management skills for chronic pain, and while it doesn’t overwhelm with vast amounts of information, it certainly contains the critical elements.

The therapist manual provides some additional supporting information and references to further readings, and also provides ways to vary or extend the skills and strategies provided in the workbook.

What I liked about this workbook is its brevity and clarity. It doesn’t provide a huge amount of information, and it doesn’t go into detail – it’s clearly meant to be used alongside input from a therapist. It has plenty of space for individualising aspects, including a number of very clear worksheets, and specific learning activities for between each clinic-based session. I also liked the layout which is very simple and clean, and although it doesn’t have diagrams, it does have good examples and bullet-point summaries.

I also liked the specific chapter on relapse prevention, something that can be problematic for many.

What I thought wasn’t quite so helpful is that this workbook is definitely one you would need to work through with a client. While there is less detail in it, so non-readers would probably cope better with it than the other workbooks I’ve reviewed, there is still a lot of reading and writing to do. It assumes the person is ‘ready’ to take action, rather than ambivalent, and it assumes also that the person can and will integrate the skills – and then go ahead with ‘normal life’. It doesn’t focus on long-term ‘life’ goals, and it doesn’t emphasise reconceptualising yourself (the client) as a person rather than a patient.

Overall, I think this book is a real asset for therapists seeking a summary book they could provide to clients to refresh their memories after having completed individual or group sessions. While it’s not detailed, it does emphasise the things that seem to be associated with improved function – especially the ‘homework’ aspect. It would be best paired with a functional approach, and like every other workbook I’ve seen so far, it doesn’t even touch momentarily on returning to work and whether these skills can be transferable to the workplace. It also focuses on control and containment rather than acceptance and mindfulness – so for some people it might not be the best approach.

Managing Chronic Pain: A Cognitive-Behavioral Therapy Approach Workbook (Treatments That Work) (Paperback)
by John Otis (Author)
Paperback: 96 pages
Publisher: Oxford University Press, USA; 1 Workbook edition (September 24, 2007)
Language: English
ISBN-10: 0195329171
ISBN-13: 978-0195329179

Managing Chronic Pain: A Cognitive-Behavioral Therapy Approach Therapist Guide (Treatments That Work) (Paperback)
by John D. Otis (Author)
Paperback: 128 pages
Publisher: Oxford University Press, USA; 1 edition (September 24, 2007)
Language: English
ISBN-10: 0195329163
ISBN-13: 978-0195329162

It’s about $80.00 for the therapists book, and about $40 for the workbook – not cheap, but discounts for multiple purchases may apply if you ask nicely!

Living beyond your pain – an Acceptance & Commitment Therapy approach to pain management

Well, that was a title and a half!
Yes, today’s review is about Living Beyond Your Pain, a workbook written by Joanne Dahl & Tobias Lundgren, with a foreword by the ubiquitous Steven Hayes, and yes, it’s published by New Harbinger Publications (again!). I want to promise, with my hand upon my heart, that I’m not in their pay-packet, and I will review something published by someone else very soon!!

Anyway, this book is based on the ACT model, which suggests that rather than trying to control your thoughts or the uncontrollable (your chronic pain), it’s preferable to live aligned to your values, and bring pain along for the ride. By neither focusing on, nor ignoring pain and judgements about your pain, it’s possible to take committed action and do valued activities instead of avoiding activities because of your pain.

Initially the ACT approach can be a little difficult to grasp, or at least that was my first impression. After reading quite a lot including the Association for Contextual Behavioural Therapy website, I have learned a bit more about it, but I still think the description in Living Beyond Your Pain is a basically sound one. Not easy to understand – but perhaps that’s because the approach itself is so different from the standard CBT approaches.

The workbook is, like all the other New Harbinger Publications books, well-designed with lots of white space, clear layout, and plenty of space for personalising and completing activities throughout.

It starts with establishing that most other strategies have not worked – creating a concept that I like of ‘creative hopelessness’ or ‘positive surrender’. To a Western audience, the very idea of surrendering or losing control to something that is unwanted is quite a strange idea, but as the authors in this workbook point out ‘Have you ever come to a point in your struggle with pain where you simply said ‘I can’t fix this’? What did that feel like? You may have experienced some grief, but wasnt there also a certain freedom?’….’We define creative hopelessness as a place where new possibilities for changing your life arise.’

Like most of the other workbooks, it also has chapters on ‘what is chronic pain?’, awareness of thoughts – and distinguishing between thoughts and the person thinking the thoughts. In terms of skills, the book covers the practice of ‘mindfulness’. This originally buddhist practice involves becoming immersed in sensations happening NOW rather than thinking about, recalling, predicting or even labelling the experiences. It is a meditation practice, but in this book it’s described as becoming a ‘watcher’ or ‘observer’ of your own thoughts – and not judging or evaluating your experiences or thoughts.

The workbook also, and very importantly, covers the ACTION part of the ACT practice. Not only is mindfulness used, but acting according to what is important or valued – and sticking to that action. By being appreciative of why you want to do something in a positive way is a much more enjoyable experience than gritting your teeth and ‘just getting on with it’.

Finally, the book finishes with ways to maintain action, and how to face barriers that are certain to be in the way of making forward momentum.

The strengths of this book are, like all New Harbinger workbooks, great layout, authoritative authors, the individual learning activities all the way through so the content is readily made relevant to the individual, and the use of a relatively new approach to living with chronic pain. Some of the activities, especially around ‘values illness’ and what people have given up to avoid experiencing pain are particularly profound and challenging when used with people who have chronic pain, and can be very persuasive for helping people consider what is important in their lives.

What I found less helpful was the slightly complex and convoluted way that ACT was described (mind you, I haven’t found anything much easier either!), and it does require good cognitive function (these concepts are abstract). As with any workbook, the reader would have to be committed to making his or her way through the whole workbook, and it’s definitely much easier to do this with a therapist helping the process. I would also have loved some more diagrams – they really make the points so much more easily.

To summarise? I wouldn’t use this book as a first-line approach to pain management, and I think it would be very important to do some further learning around the ACT approach before starting to use this workbook with clients. On the other hand, excerpts from this book are great – especially the concept of ‘clean pain’ which is essentially about experiencing the sensations and ‘dirty pain’ which is about judgements about having that pain.

Living Beyond Your Pain
Using Acceptance & Commitment Therapy to Ease Chronic Pain
By Joanne Caroline Dahl, Tobias Lundgren
Publisher: New Harbinger Publications
ISBN: 1572244097
EAN: 9781572244092
Format: Paperback, 169 pages
Published In: United States, May 2006
Other Editions: Paperback, USA $56.99
$34.20 from Fishpond – reduced from $45.99,

Self Help Books: A behavioural assessment approach to chronic pain

Today’s self help book is published by one of the more prolific publishers of psychological self help – it’s from the New Harbinger Publications stable of self help books.

The Chronic Pain Care Workbook; A self-treatment approach to pain relief using the behavioural assessment of pain questionnaire is written by Michael J Lewandowski, a clinical psychologist with years of experience working with people experiencing chronic pain. He has developed the pain assessment tool used in the book, called the Behavioural Assessment of Pain assessment, which has been used internationally for pain assessment, and forms the basis of self discovery for people working through the workbook.

Like most chronic pain workbooks, this workbook is designed to reassure people that their pain is understandable, to a certain extent, able to be managed if not controlled or reduced, and to help people to take steps to return to a normal life. What is slightly different about this book is the extensive use of self assessment across a wide range of areas to form a ‘Pain Scorecard’ – and thankfully, there is some empirical support for the assessment norms (just not norms developed for New Zealand!). There are actually 29 individual subscales comprising areas such as Pain Intensity, Sleep Interference, Fear of Re-Injury, Pain Behaviours, several Interference scales, and several relevant to ‘significant others’ in the person’s life.

For each subscale there is a separate questionnaire, many quite brief, that are asked throughout the book – and the scores are arranged in terms of areas of strength, concern and significant concern. Subscales can also be arranged by category, and the book provides specific solutions for ‘common areas of concern’.

While it’s possible to complete all the questionnaires before reading through the book, and therefore only dipping in and out of relevant chapters, it’s preferable to work through the book chapter by chapter, reviewing each area in the order indicated. This makes the workbook a little less daunting (it’s over 200 pages long), and the chapters do flow in a reasonably logical order.

Chapters include:
Part 1 – what is chronic pain, including definitions of chronic pain, the biopsychosocial model, readiness and intention for change, baseline pain ratings and goal-setting, and a brief review of diagnosis
Part 2 – Behavioural assessment of change, including fatigue, medication, thoughts and ideas, pain behaviours, activity interference and avoidance, emotional pain, family and social, sex and intimacy, and working with the health care team
Part 3 – Conclusion – setback planning, progress monitoring, acceptance
Part 4 – the Pain Scorecard and interpretation

The strengths of this book are the individual learning activities all the way through, ensuring that for the committed reader, the content is readily made relevant to the individual. It also uses quite clear language, there is room to breath (white space!) on each page, and it’s possible to complete all the exercises within the workbook.

I also liked the reference to stages of change, personal goals (the reasons for using this workbook), and the use of both behavioural and cognitive strategies. None of the strategies are particularly new or unique, but they are very relevant and low-cost. One example is the use of blue dots placed around the environment as a cue to notice and use a brief relaxation technique. Recording charts are also included for activities that can be used on a daily basis.

The aspects I felt were less helpful was the sheer volume of information, and some of the language is probably well beyond the people I work with. Like any workbook, it’s attempting to be ‘all things to all people’, so most people would probably appreciate having a therapist work through it with them – at the very least to get all the way through it! I would also have appreciated some diagrams, or visual aids that didn’t include words – personal preference, but probably applicable to a good number of people who would want to use this type of book.

Overall? A helpful workbook, but very in-depth, and probably would need someone very committed to complete it without support. Certainly a lot easier to read and follow than the Nicholas, Molloy, Tonkin & Beeston book I reviewed yesterday.
The Chronic Pain Care Workbook: A Self-treatment Approach to Pain Relief Using the Behavioral Assessment of Pain Questionnaire (A New Harbinger Self-Help Workbook)
by Michael J. Lewandowski
Paperback: 223 pages
Publisher: New Harbinger Publications; 1 edition (November 2006)
Language: English
ISBN-10: 1572244704
ISBN-13: 978-1572244702
It’s roughly NZ$30 and readily available.

A week of self help books!

I hope to spend a little time reviewing self help books for chronic pain management – please note I don’t sell them, I just buy them! Anyone looking in my office will realise I spend wayyyy too much time in, and they make waaaayyyy too much money out of me!

Anyway, a quick review of one book today – more tomorrow.
This one is a bit of a standard, Manage your pain by Michael Nicholas, Allan Molloy, Lois Tonkin and Lee Beeston. It’s readily available, not overly expensive, and endorsed by Prof John Loeser, University of Washington, Seattle.

It’s designed to be complete, includes a lot of information, and for a self help book, spends quite a lot of time looking at investigations and treatments that may be used by medical professionals. Chapters include ‘What’s going on in your body when you have pain?’, ‘What X-rays, CT and MRI scans tell us’, ‘Working with your Doctor’, and ‘Treatments for chronic pain’. Then it starts in on the good stuff – Pacing, setting goals, recognising obstacles to change, stretching and exercising, challenging ways of thinking etc.

Three observations about this book –
1. On the helpful side, it’s Australasian, so for those of us from Down Under it refers to things quite familiar.
2. On the not so good side, I found it quite text-dense which could be off-putting for so many of the people I work with who have very limited literacy.
3. The other not so good aspect is that it doesn’t include worksheets or ways to personalise the application of strategies to an individual. I think it could be quite easy to glance through the book and just not use the very helpful information that is included.

I’d suggest this book is one you might provide as a supplement to individualised input by a health professional, and perhaps set individualised goals as you and the client work through the contents. Or it may be one that is held as a reference in a health centre, with certain chapters provided to the person with chronic pain as needed.

Oh, by the way – I hadn’t heard of Fishpond online bookstore in New Zealand until a couple of weeks ago – yet another place I’ll need to lock up my credit card from!!

Manage Your Pain
Practical and Positive Ways of Adapting to Chronic Pain
By Michael Nicholas, Allan Molloy, Lois Tonkin
Format: Paperback, 224 pages
Published In: United States, September 2006
Publisher: Souvenir Press
ISBN: 0285636790
EAN: 9780285636798

Working with goals

I mentioned in my post yesterday that it’s not easy to help people work out goals.  Most people have a fairly general idea of how they’d like their life to be, despite pain, but have lost sight of the possibility of how life might be in the future. I spoke about this with a person this morning who told me that he has lost confidence that life can be anything different, so when he was asked ‘what do you want from pain management’, he was floored!  He told me that he has lived ‘from day to day’ for so long that he had lost sight of considering where he was going in his life. I don’t think this is uncommon for people living with long-term pain, before they start accepting pain as chronic and start ‘living’ with their pain.

So the first step may be to use a menu approach as I suggested yesterday, but somehow this needs to lead in to longer-term ‘life change’ goals, so the new knowledge can be integrated and retained.  My vision for people learning to live with pain is that they move from thinking of themselves as ‘patients’ and move to thinking of themselves as ‘people’ – and more importantly, that they are people who are doing things. That way their pain condition becomes no more important a part of them than their height, ability to do maths, or interpersonal skill: just part of who they are.

We’ve discussed the menu approach, which helps people to look at things they’re interested in.  Then quite often we help the person develop the pain management skills are linked to the clinical hypotheses we, as clinicians, developed about the factors that we have assessed as influencing their pain presentation.  These are may be things like activity management, relaxation training to reduce physiological arousal, communication skills and so on…

Then the part that I think is vitally important, but not always recognised: change management in ‘real life’.  Some people call this ‘goal setting’!

The ‘wish list’ (I promise I’ll feature this tomorrow!) asks people to identify general areas they’d like to see change in their lives.  This goal-planning worksheet is one way to help people develop specific ‘next steps’ to take, and ways to identify and measure the actions and resources they need to take to make it happen.

Click on it, and you’ll be able to see that in the centre is the ‘goals area’. I’ve described this as ‘I want to…’ with lots of space to draw or write exactly what the person wants. If they can’t be very specific, that’s fine because details are refined as part of this worksheet process.

Starting at the top, working clockwise, are a series of headings that the person can complete that will help shape up the way to achieve the ‘I want to’ part. Going in order is important (from top, clockwise), because each section builds on the others.

Step one and probably most helpful for retaining motivation is ‘Why is this important to me?’. We know that internal motivation is drawn from values, or reasons that something is important. By helping the person think through why they want this change, we help them generate their own reasons for change, rather than reasons we might generate.

Step two is about time frame: often this depends on the level of confidence the person has for acheiving their goal.  The time frame also may determine the steps the person may take, and reflect other people’s actions or proceses (eg case manager). It may be helpful to revisit the time frame once other areas are completed and adjust, but it’s useful to work out what the person believes is possible first.

Step three is about where the goal will be achieved – for example, at home, at work, in a clinic… This may help determine the strategies that can be employed.  Some activities can be used in one setting, but not another, while it may be important to help the person see that they can achieve in one setting before generalising to another (eg using relaxation at home to enable them to complete vacuuming, before developing the skill to self-regulate at work, where it can be much more difficult).

Step four asks about general resources the person may need. This can be revisited also, but is often the real action phase of goal setting.  It’s OK to not know all the resources required – this may, in fact, be one of the sub-tasks required to achieve a goal.  So it’s fine to put down ‘I don’t know what resources are available – I’ll need to identify these as my ‘next best step” – which is one of the other steps in this process.

Step five identifies the ‘people’ resources the person has to help them achieve their goal. This can range from speaking to their partner, family or friends, right through to asking for a referral to see a specialist career counsellor.  If the person is receiving compensation, and has a case manager, then the case manager must be one of the ‘people’ identified in this step.  You, as health provider, should also be listed.

Step six is about what the person can do to recruit help from people – because it is all about self management and self responsibility.  What does this person need to do to get the help they want? Do they need to write letters? Meet with someone? Leave notes? Arrange regular phone calls?

Step seven identifies ‘what are my next best steps?’. This can be about finding out resources, contacting people who can support them, maybe identifying where the goal can be carried out, or even refining the time frame.

Finally, (and next to ‘why’, the most important part of this process) is ‘how will I know I’ve achieved my goal’. This is often the most challenging part of this whole process, because it provides the person with a specific way to measure achievement. This may require additional input from you as health care provider.

It’s not very easy for someone to think about how they will know whether they have achieved a goal – quite often the person hasn’t thought about the goal in more than general or vague terms.

For example, a goal may be ‘to sleep better’.  This isn’t precise enough for anyone to decide whether the goal has been achieved or not.  Remember that subjective feelings ‘sleeping better’ are often determined by proximal experiences (a bad night’s sleep or two close to the day the person is asked about their sleep will likely influence them to say it is no better), and by demand characteristics of the person asking (a treating clinician will obtain a different answer than if the person’s partner asks), as well as a number of other response biases.

It’s far more effective to ask the person ‘how will you (know) measure that your sleep is better?  Is it that you sleep all the way through the night, every night of the week?  That you wake up feeling like you’ve had a good sleep, five days out of seven?  That you no longer use any sleeping medication to help you get off to sleep?’

These latter measures help identify the different ways that ‘success’ can be achieved, and as a result both reduce the chance for measurement biases as well as determine just what the ‘end point’ will be (at what point will the person be personally satisfied with their progress?).  It’s much more client-centred, as well as more easily recorded and reproduced.

Have a go at using this worksheet for a person goal for yourself.  What would you like to see different in your life?  Then work out how you’ll achieve it using this step-by-step process.  Let me know how you go!

Useful resources: handouts on basic coping skills

Trawling through the interweb can be enlightening sometimes. What’s exciting is to see the range of resources government agencies provide. I’ve just spotted these from the Centre for Clinical Interventions (CCI) from the Department of Health, Australia.

This list of fun activities in pdf includes some social ones as well as solitary ones, and many of them are low-cost and low in organisation. Great for people who are feeling a bit low and can’t get themselves together enough to do anything particularly complex.

And this one on assertive communication pairs quite nicely with this one on anger coping strategies to provide people who are struggling with frustration and irritability with some specific skills to let off steam.

I like the list of specific information on topics like this one on stress and this excellent one on sleep hygiene.

In addition to these, they have several manuals for health professionals working in mental health – none for general health, unfortunately. One day health will be considered as one single entity rather than divided into ‘mental’ and ‘physical’!!