The Practical Pain Management Handbook

The Essential Evidence-Based Guide

Dr Keren Fisher, Susan Childs, Susan Childs

• Publisher: Routledge
• Year: 2018
• ISBN:
  9781351697811
• Edition: 1
• Topic: Médecine
• Subtopic: Anesthésiologie et gestion de la douleur

The successful management of chronic pain remains an elusive goal. As more complex diagnostic and intervention procedures become available, patients and clinicians alike have ever-greater expectations of banishing the problem of pain altogether. Unfortunately this hope is rarely fulfilled and the frustration experienced by everyone affected by chronic pain has remained more or less the same over the last two or three decades. Based on over 40 years' of experience and research The Practical Pain Management Handbook is a unique resource specifically designed for therapists involved in running Pain Management Programmes (PMPs). This engaging and effective handbook includes: intensive inpatient and extended outpatient programmes all of which are at least 25 hours in length; interactive materials designed to be used to form the basis of group discussion. Where there is a question in the text the suggested answer material is provided; assignments and tasks that can be used as homework or group session exercises; both standard Cognitive Behaviour Therapy (CBT) and Acceptance and Commitment Therapy (ACT) technologies as both have been found to be valuable in PMPs. The handbook is organised into sections to fit a useful logical sequence but can be adapted to suit your preference.

1
Introduction for Therapists

 

 

The successful management of chronic pain remains an elusive goal. As more complex diagnostic and intervention procedures become available, patients and clinicians alike have ever-greater expectations of banishing the problem of pain altogether. Unfortunately this hope is rarely fulfilled and the frustration experienced by everyone affected by chronic pain has remained more or less the same over the last two or three decades.

 

Pain management programmes (PMPs) are popular for their ability to help patients and their families understand and cope with the transmission of abnormal neural stimulation, its subsequent experience as pain and its related disability, distress and adverse life effects. However, programmes vary in their mode of delivery and in their inputs and outcomes. There is no absolute format, as each programme will depend on the available resources and current thinking.

 

For many years we have been using and adapting mental health texts to meet the needs of our chronic pain patients. It struck us that there should be a book specifically for therapists involved in running PMPs and we recognised the need to have access to a greater variety of suitable teaching and interactive materials than we could find.

 

Between us we have over 40 years’ experience of learning from our mistakes and trying to hone our programmes until they are as engaging and effective as possible. The information in this handbook is the result of our most developed thoughts and accumulated know-how to date, but of course there will always be new ideas, political interests and research findings to change the prevailing philosophy.

 

We have discovered that there are both gains and losses to be had from both intensive inpatient and extended outpatient programmes, as long as they are of at least 25 hours in length, with about 8-12 patients in a group. Smaller numbers dilute the social learning effect and may reduce the cost-effectiveness of the programme. Shorter programmes are reported to be less effective.

 

Whether you choose to have inpatient or outpatient programmes depends on your resources. The British Pain Society reports that the degree of patients’ distress and disability may contribute more to treatment outcomes than whether or not the patients are residential. The core recommendation is that the staff should be specifically experienced and involve (in addition to a medically qualified person) a chartered clinical or health psychologist (or a suitably qualified cognitive behavioural therapist) and a chartered physiotherapist. The addition of a nurse and occupational therapist with specific competencies in chronic pain management is a great advantage.

 

We suggest the programme format needs to begin with a multidisciplinary assessment session. While this might involve patients still having to wait for admission to the main bulk of the programme, information is discussed during the assessment that enables patients to understand the principles they will encounter in later weeks and which significantly reduces the drop-out rate once the programme has started. We discovered the assessment session began the process of change, so patients joined the programme already experiencing less pain and distress than had been identified at referral.

 

We also found that follow-up sessions (which could occur incrementally at three months, six months and a year) in which important outcome data should be recorded, were not often well attended. To address this common problem we began encouraging patients to attend by offering them a variety of booster workshops in which they could revise their skills in stretching exercises, relaxation and mindfulness, cognitive challenges, problem solving or new goal attainment. These workshops have proved to be enjoyable and successful.

 

We have organised this handbook into the sections we think fit a useful logical sequence but you must adapt them to suit your preference. Some sections require more than one session. You must split up the material as you think fit.

 

The material really needs to form the basis of group discussion rather than didactic teaching. Where there is a question in the text the suggested answer material is provided, but you may wish to withhold this while you ask for contributing answers from the participants. In our experience we find that the most important messages are best remembered through the language the patients generate themselves.

 

Where assignments are given as homework, ask for feedback and reports of any problems at the beginning of the very next session. When we inadvertently forgot to do this ourselves, we found compliance dropped off and learning opportunities were missed.

 

We have incorporated both standard cognitive behavioural therapy (CBT) and acceptance and commitment therapy (ACT) technologies, as both have been found to be valuable in PMPs. The table presented in this introduction shows the similarities and differences between CBT and ACT techniques, which may be of use to you in planning your sessions.

 

While we generally believe the mindfulness approach to defusing the influence of thoughts on actions is valuable, our experience has shown that particularly persistent or ‘sticky’ thoughts benefit more from a CBT approach.

 

Pages headed ‘A task for you’ can be homework or group session exercises. Therapists involved in running PMPs should refer to the enclosed CD for printable versions of the Tasks. However, Section 18 (Pain Management Programme Problem Pages) is intended to be a group assignment - we suggest you copy the pages and cut them up into separate problems so patients can choose which ones they would like to work on.

DIFFERENCES BETWEEN TRADITIONAL COGNITIVE BEHAVIOURAL THERAPY AND ACCEPTANCE AND COMMITMENT THERAPY

CBT encourages people to analyse their thought content and to see how it has influenced their emotions and reactions.

 

ACT, on the other hand, asks people to reduce the influence of thoughts on emotions and actions and to see thoughts as just passing events in the mind. Thoughts don’t need to be glued or fused to a particular response. Instead, ACT encourages action guided by life values.

Principal CBT techniques	Principal ACT techniques
Encourages detailed examination of thoughts (Exactly what were the thoughts in that situation?)	Attempts to remove influence of thoughts on emotion and behaviour
Analyses thoughts for ‘distortions’ or ‘errors’	Encourages thoughts to pass along as events in the mind without judging them
Looks for alternative thoughts or interpretations of a situation	Uses metaphors to encourage new views of a situation (e.g. if in a hole, trying to dig a way out will aggravate the situation)
Uses verbal questions to clarify ‘meaning’ of thoughts or interpretations of a situation	Discourages analysing thoughts for meaning
Looks for evidence to prove or disprove thoughts	Reduces emphasis on verbal ‘rules’
Seeks to change verbal interpretation in view of evidence	Encourages discovery of what is helpful via experience
Keeps its focus on verbal influence of thoughts on emotion and behaviour	Keeps its focus on awareness of present moment-to-moment experience
Focuses on moving towards tangible goals	Focuses on moving in the direction of life values
Uses Behavioural experiments	Uses Behavioural experiments
Uses Homework tasks	Uses Homework tasks

We would appreciate feedback from your experience of running programmes based on this handbook. We can be contacted via Speechmark Publishing Ltd.

 

Dr Keren Fisher
Consultant Clinical Psychologist
Dr Susan Childs
Consultant Clinical Psychologist
June 2014

2
Pain Management Programme Introduction: Multidisciplinary Assessment Session

This session is about assessing how your pain affects your life and how you are dealing with it. You will have a chance to learn more about the pain management ...