My thoughts on the “CB Perspective” in Massage therapy based on the following two articles provided by Bronnie Lennox Thompson to support the argument that RMTs (or non-psychology professionals) should incorporate CB approaches in pain management interventions.

After reading the following articles (I read the fill articles, not the abstract),

I stand by the concerns that I have, that RMTs are NOT:
– in a position to be able to apply CB interventions that involve eliciting or modifying a client’s belief.
– in a position to assess the severity of comorbid conditions to determine the appropriate course of action.
– in a position to practice “CB approaches” without appropriate collaboration from other HCPs that have the credentials in this area.

I still don’t see how these proclaimed “CB approaches” differ from CBT for mental health other than its attributes to pain management instead of anxiety or depression (for example). Even though the articles claim it is different. It is not clear how. Perhaps Christopher Moyer can help me understand this better.

I maintain my acknowledgment that a cognitive-behaviour model is effective for chronic pain according to the evidence, but in order for it to be carried out effectively, RMTs need to collaborate with psychologists or other HCPs that have been authorized to practice it.

I maintain that we need to be conscious of working within our scope of practice and know the boundaries for when we need to collaborate with others and/or refer out.

I maintain that we, as a profession are lacking general knowledge and competency in mental-health related conditions and that something should be done sooner than later to fill that gap so that our clients can obtain the support they need and so that we can have the confidence to know:
a) How to manage a mental health crisis
b) When to refer out
c) When to collaborate with others and how to collaborate with others effectively.
d) How to think critically about mental health and how it affects our treatment, and how our treatment may affect someone’s mental health.
e) How to use our judgment safely while maintaining our boundaries within our scope of practice when these grey areas arise.

So in summary, there is nothing in the articles that surprised me enough to change my position on any of the posts I had made….

On a personal note (and a testament to why I love being challenged in debates like this…) I was particularly taken by the Operant Conditioning aspect and how we can be enabling clients by being over-sympathetic to their pain. Something to think about – I will definitely take that one away for my future consideration in my own practice.

My comments to specific quotes and points within the articles that make up my position are highlighted below in bold.


Cognitive-Behavioral Approach to the Treatment of Chronic Pain Patients

Dennis C. Turk, Ph.D

• “Cognitive-behavioral treatments should be viewed as important complements to more traditional pharmacological, physical, and surgical interventions.” No one is disputing the effectiveness of CB approaches for pain management. This is not suggesting that practitioners without credentials could be practicing this safely.

• “Health care professionals, as well as family members, may reinforce and thereby increase pain behaviors” Interesting point based on Operant Conditioning, how do we find the line between being empathetic and not enabling clients

• “Research suggests that 40-50% of chronic pain patients suffer from depression” This citation was out of date (1989) a more recent study I 
know of suggests 70% according to this source: Depression in chronic pain patients: prevalence and measurement, Poole H, et al. Pain Pract. 2009 May- Jun. I didn’t search through all of the citations, but it leads me to wonder how many other citations were out dated…

• “It is important to be aware of the role of negative emotions in chronic pain because it is likely that they will have an impact on motivation for and adherence to treatment recommendations. For ex- ample, patients who are depressed and who feel helpless may have little initiative to comply; patients who are anxious may fear engaging in what they perceive as physically demanding activities; and patients who are angry at the health care sys- tem are not likely to be motivated to respond to recommendations to exercise.” What makes us think that we are qualified to assess the severity of depression, anxiety, or anger and if these factors are present along with the chronic pain, how are we qualified to intervene within our scope of practice?

• “The CB perspective focuses on providing the patient with techniques to gain a sense of control over the effects of pain on his or her life as well as actually modifying the affective, behavioral, cognitive, and sensory facets of the pain experience and problems associated with persistent pain. Behavioral experiences help to show patients that they are capable of more than they assumed, increasing their sense of personal competence. Cognitive techniques (for example, self-monitoring to identify relationship among thoughts, mood, and behavior, distraction using imagery, and problem-solving) help to place affective, behavioral, cognitive, and sensory responses under the patient’s control. The assumption is that long-term maintenance of behavioral changes will occur only if the patient has learned to attribute success to his or her own efforts.” HOW does this differ from traditional CBT with respect to not needing the same level of credentials to administer this? Perhaps Christopher can answer this one for us…

• “physical therapists need not only to address the patient’s performance of physical therapy exercises and the accompanying attention to body mechanics, but also to address the patient’s expectancies and fears because they will affect the amount of effort, perseverance in the face of difficulties, and adherence with the treatment plan lets look at this…if we were to consider this so-called “CB perspective” as it is defined, we would be considering 5 factors that may be limiting the client’s success rate of follow through for the home care activities: 
1) people actively process information, 2) Thoughts influence behaviour, 3) Behaviour is determined by both the individual and the environment, 4) Successful interventions should focus on altering the maladaptive thoughts, feels, and physiology, 5) People should be considered agents of change of their maladaptive thoughts. 
This basically just means that we need to be aware of these things. These 5 factors have the potential to guide us in the decision making processes we need to go through such as…

How can I assist within my scope of practice? – Be a good listener, don’t have an agenda.

– Recognize that extenuating circumstances are involved and so our thoughts around the circumstances. Validate appropriately without enabling.

– Refer out for interventions on eliciting and altering maladaptive thoughts.

– Encourage clients to be in control of their progress by involving them in the progress report writing, encouraging them to attribute their success to them not to you.

• “CB interventions are designed to help patients identify maladaptive patterns and acquire, develop, and practice more adaptive ways of responding. Patients are encouraged to become aware of, and monitor, the impact that negative pain- engendering thoughts and feelings play in the maintenance of maladaptive behaviors.” What makes us qualified to do this successfully and safely? It takes years of experience and education and supervision to intervene safely and effectively when manipulating maladaptive thoughts. There is no mention in the article that this should be executed by people who do not have the proper credentials.

• “Interdisciplinary pain rehabilitation programs are the treatment of choice for patients with recalcitrant chronic pain. These comprehensive programs are more effective than no treatment,…” This statement seems to support my argument that a collaborative approach with other disciplines such as a psychologist who specializes in CBT, or another profession that is recognized as having the credentials for intervening in this manner for pain management is what is beneficial vs. RMTs trying to do it all themselves. 


Extending Physiotherapy Skills Using a Psychological Approach: Cognitive-behavioural management of chronic pain

This article refers to several points that are considered to be using a CB methodology to manage chronic pain.

1) Pacing:

I agree that pacing out the activities in to more manageable ones is within our scope.

2) Cognitive restructuring:

According to the article…“The cognitive component of a CP management programme involves teaching patients to identify thoughts and beliefs which underpin maladaptive behaviours and which adversely affect mood. There is a particular focus on anxiety and depression. Once patients can identify the very disabling cognitions, they try to use cognitive restructuring to identify and challenge long- standing beliefs and immediate judgements (Turket al,1983), with resultant improvement in mood and in practical coping with the pain. Cognitive restructuring is a task that varies in complexity. Although this complexity sometimes requires the specialised skills of clinical psychologists or others with appropriate training, there are many occasions when less experienced professionals may help patients apply the principles to great effect.” The way I understand this is that there are a handful of other professions, such as physicians and occupational therapist that do not have the specialized training as such, but they have been recognized to provide this intervention. It doesn’t mean that RMTs are able to do it safely and effectively. How would an RMT be able to determine if this is something more complex without having the knowledge, skills, and abilities to properly assess that with years of education, experience, and supervision?

3) Relaxation:

Sure that is within our scope. But … did you know that some experts believe that in some cases relaxation can actually induce panic (ex. in situations where the panic is caused by internal sensations). We would have no way of knowing this because our curriculum does not incorporate mental health pathologies so we are not privy to the contraindications for massage and/or the effects of relaxation on such disorders.

Other points:

The article mentions: “The psychologist and physiotherapist together carry out the core face- to-face therapeutic work” The focus here is on collaboration – there is no expectation that the physio is carrying out the work – what makes us think we, as RMTs are above that?

According to the article, the physio’s role in psychology is

1) changing behaviour:

“Providing positive consequences for learning a new behaviour such as a previously feared exercise is likely to reinforce it”

YES Absolutely but… in order to know what the fears are, the physio/ or RMT in our case would collaborate with the psychologist who should be the one to elicit that appropriately from the client first.

2) Goal setting:

Yes – setting realistic achievable goals that are measurable and time-bound is completely appropriate for us to do.

3) Pacing:

YES – Pace out the home care according to the baselines agreed upon with the psychologists and the individual needs of each client. Because determine what the right pace is for the client is out of our scope of practice and outside what we are trained to do safely and effectively.

4) Education:

Clear communication, easy to understand, what needs to be done so that the client can decide to do it? Totally do-able by RMTs.

5) Recording progress:

Involve clients in it (level of involvement should be based on feedback from psychologist)

6) Challenging thoughts and feelings:

Although the article suggests Physios could this, I don’t agree that this should be done blindly by Physios, or RMTs. – The psychologist and the client should both agree on what thoughts and feelings could be challenged. I believe that this is where much of the debate comes from – should RMTs have more control over challenging these thoughts. I don’t believe so. Not in our scope… not unless there are clearly defined fears that have been addressed with the psychologist and shared with the RMT before-hand.

7) Reminding clients that they were responsible for the positive outcome / achievement vs the Physio/(RMT) or psychologist when they try to say “thank you etc”. YES – totally within our scope and in accordance with our value principles.

8) Allow clients a sense of control…

Sure, give them options as you educate them about what their body is capable of doing. Let them find out on their own (teach them how) that their body is capable of doing more. I would still have the client consult with their psychologist if they are having difficulty with this concept, but empowering clients is within our values.

9) Don’t dismiss pain, but don’t enable the response to it.

There are strategies we can learn about how to do this effectively. Be confident but not aggressive in your communication / motivational approach. This is not psychotherapy. This is used in business, in marketing, and in healthcare to motivate people to adhere to their goals.