New approaches towards chronic pain: patient experiences of a solution-focused pain management programme

摘要

Research has suggested that Solution-Focused Brief Therapy (SFBT) may be effective in facilitating meaningful change for those living with chronic pain. This study aimed to further this understanding through exploring the experiences of people living with chronic pain, who had attended an 8-week solution-focused pain management programme. The design of this study was conducted in consultation with a service-user advisory group, and employed a qualitative and interpretative design rooted in critical community psychology, participatory research frameworks and emancipatory disability research. Five participants opted-in to the study following an opportunity sampling method of persons who had attended a programme in the last 18 months. Interviews were transcribed verbatim and analysed using inductive thematic analysis. Five main themes were identified: ‘Accessing the pain management programme’, ‘A solution-focused group’, ‘The solution-focused clinician’, ‘Solutions and changes’ and ‘Challenges and improvements’. Clinical and research implications of the findings are discussed.Summary points class="enumerated" style="list-style-type:decimal" id="list1-2049463713516755">There has been an international proliferation of pain management programmes (PMPs) aimed at helping those with chronic pain to live well, despite an unremitting condition.Arguably, the most popular psychological approaches used within PMPs are informed by cognitive behavioural therapy (CBT).Despite a supportive evidence base for psychological approaches in pain management, there is a recognised need for further research into alternative approaches and their effectiveness.Emerging research and policy recommendations are beginning to value the expertise of those living with chronic conditions, particularly how these perspectives can be used to develop effective treatments and services.SFBT is an approach aimed at achieving a patient’s goals or ‘preferred future’ through identifying and utilising their expertise. SFBT may have significant efficacy in helping those with chronic conditions to live improved, meaningful lives. class="kwd-title">Keywords: Solution-focused, chronic pain, pain management, qualitative research class="head no_bottom_margin" id="section2-2049463713516755title">IntroductionChronic pain has the potential to negatively impact patients across multiple domains. Research utilising a variety of methodologies has consistently demonstrated that this impact breaches multiple aspects of the self, including – but not limited to – physical, neurological, psychological, social and spiritual concerns.The breadth of this impact may be reflected in the changing emphasis towards biopsychosocial and holistic approaches to health care that are increasingly being encouraged in medical practice and policy. Moreover, as chronic pain is among the most prevalent of chronic conditions, there has been an increase in the availability of ‘Pain Management Programmes’ (PMPs) which attempt to offer accessible understanding, education and support to the significant number of people living with chronic pain (see The British Pain Society’s Guidelines for pain management programmes for adults).Patients with chronic pain are encouraged to take an active role in self-managing their symptoms. Consequently, PMPs often focus on domains judged to be more amenable to change – particularly behavioural and psychological modifications in one’s response to pain. Arguably, the most popular psychological approach is ‘Cognitive Behavioural Therapy’ (CBT), which is among the most evidence-based psychological treatments in Western medicine for physical health concerns. A recent systematic review suggests that CBT is effective in the management of chronic pain, with successful outcomes sustained upon mood and catastrophising at 6 months after treatment, although improvements upon pain are weaker and only significant immediately post treatment. Newer treatment approaches drawing on CBT theory are also gaining evidence, such as ‘mindfulness’ and ‘Acceptance and Commitment Therapy’ and may be helpful in ascertaining which types of psychological approach work best for which type of patient and why.Another emerging psychological approach within health care is Solution-Focused Brief Therapy (SFBT). SFBT can be briefly defined as an approach which builds upon a client’s inherent competence, with the aim of facilitating goal-directed action. SFBT provides a framework designed to elicit a person’s best hopes (or ‘preferred future’), and to reveal existing personal resources – often with the aim of amplifying the frequency or likelihood of a desired outcome. Techniques include developing concrete and behavioural descriptions of a preferred or hoped-for future (e.g. How would you like things to be different?), noticing exceptions to target problems (e.g. When has your mood been best this week?) and utilising 0–10 scaling to help clients move from all-or-nothing goals to more manageable steps. (For a fuller description of the solution-focused (SF) approach to pain management, see Simm et al.)Outcome research for SF interventions has been mixed. For instance, a recent systematic review of SFBT found that 74% of studies reported significant positive behavioural and psychological outcomes and 23% reported positive trends. Studies which examined length of treatment all found that SFBT used fewer treatment sessions than comparative interventions, and the strongest evidence of effectiveness was found in the treatment of depression. In contrast meta-analysis of 21 studies of SFBT outcome research comprising a total of 1421 patients demonstrated only small to moderate positive effects on treatment outcomes (d = .37) and was not more effective than treatment as usual. The largest effects of SFBT were demonstrated upon behavioural problems (d = .61). While direct research regarding SFBT and physical health is more limited, studies have found the SF approach to be effective in facilitating outcomes that are meaningful to those with chronic pain. For example, SF group therapy has been found to improve the rehabilitation of orthopaedic patients on sick leave in two studies (60% SFBT group vs 13% Control) and (68% SFBT vs 4% Control).While direct outcome research is lacking for SF approaches to chronic pain, existing pain literature may indicate that exploring this link further is worthwhile. Eccleston and Crombez, for instance, describe that living with chronic pain is an active process of searching for solutions, and to react passively to pain is ‘counter biological’. The emphasis on searching for solutions to chronic pain can be demonstrated through conceptual models of ‘misdirected problem solving’ (whereby patients develop problem-solving behaviours and beliefs that are ultimately unhelpful or dysfunctional to their goals), or through a number of studies indicating that the mechanism by which psychological therapies can reduce the negative effects of chronic pain is through increasing positive and meaningful behavioural change.^{href="#bibr16-2049463713516755" rid="bibr16-2049463713516755" class=" bibr popnode tag_hotlink tag_tooltip" id="__tag_478428938">16,href="#bibr17-2049463713516755" rid="bibr17-2049463713516755" class=" bibr popnode tag_hotlink tag_tooltip" id="__tag_478428934">17} The concept of a ‘preferred future’ when living with pain has also more recently been given focus by pain researchers,^{href="#bibr18-2049463713516755" rid="bibr18-2049463713516755" class=" bibr popnode">18href="#bibr19-2049463713516755" rid="bibr19-2049463713516755" class=" bibr popnode tag_hotlink tag_tooltip" id="__tag_478428942">–href="#bibr20-2049463713516755" rid="bibr20-2049463713516755" class=" bibr popnode tag_hotlink tag_tooltip" id="__tag_478428943">20} as have techniques such as focusing on successes during pain consultations.^{href="#bibr21-2049463713516755" rid="bibr21-2049463713516755" class=" bibr popnode">21} Such frameworks share key similarities with many of the core features of SFBT and recommendations for working with patients living with chronic conditions.^{href="#bibr22-2049463713516755" rid="bibr22-2049463713516755" class=" bibr popnode">22,href="#bibr23-2049463713516755" rid="bibr23-2049463713516755" class=" bibr popnode">23}Given the paucity of research examining SF approaches in physical health settings, this study aimed to broadly explore the experiences of patients who had attended an 8-week SF PMP in a community setting. It was hoped that qualitative practice–based evidence could aid the interpretation of outcome data^{href="#bibr9-2049463713516755" rid="bibr9-2049463713516755" class=" bibr popnode tag_hotlink tag_tooltip" id="__tag_533483315">9} and reveal elements of the programme participants experienced as significant.