The Psychologically Informed Practice Consultation Roadmap: A Clinical Implementation Strategy

Abstract

Psychologically informed practice (PiP) includes a special focus on psychosocial obstacles to recovery, but research trials have revealed significant difficulties in implementing PiP outside of research environments. Qualitative studies have identified problems of both competence and confidence in tackling the psychosocial aspects of care, with a tendency to prefer dealing with the more mechanical aspects of care. In PiP, the distinction between assessment and management is not clear-cut. Analysis of the problem is part of the intervention, and guided self-management begins with the initial detective work by the patient, who is encouraged to develop successful and relevant behavior change. This requires a different style and focus of communication that some clinicians find difficult to enact. In this Perspective, the PiP Consultation Roadmap is offered as a guide for clinical implementation to establish a therapeutic relationship, develop patient-centered communication, and guide effective pain self-management. These strategies are illustrated through the metaphor of the patient learning to drive, with the therapist as a driving instructor and the patient as a student driver. For convenience, the Roadmap is depicted in 7 stages. Each stage represents aspects of the clinical consultation in a recommended order, although the Roadmap should be viewed as a general guide with a degree of flexibility to accommodate individual differences and optimize PiP interventions. It is anticipated that the experienced PiP clinician will find it progressively easier to implement the Roadmap as the building blocks and style of consultation become more familiar.

Introduction

A detailed description of psychologically informed practice (PiP) and its origins¹ is presented in the accompanying paper in this issue.² In brief, PiP’s most distinctive features are the patient-centered approach to consultation, the focus on reactivation (ie, reengagement in usual activities) rather than pain, the inclusion of a specific focus on the identification of obstacles to recovery, and the development of self-management.

There have been 3 major building blocks of PiP: (1) The Gate Control Theory,³ which proposed a central role of the brain in processing and making sense of the pain signals being transmitted from the peripheral nervous system^4,5; (2) the development of behavioral approaches to pain management^6,7 and the subsequent move toward secondary prevention with its primary emphasis on reactivation and reengagement rather than pain relief; and (3) increasing interest in the social context of pain⁸ and the importance of communication.⁹

The drive toward secondary prevention stimulated interest in risk identification, screening tools, and stratified care. Studies that target treatments based on patients’ risks for poor outcomes have demonstrated improved clinical and occupational outcomes,^10–12 stimulated controlled trials, and shifted interest from outcomes to the nature of interventions and their implementation. Although there has been increasing interest in PiP, research trials have revealed significant difficulties in implementation outside of research environments.^13,14 Also, there are reports of lack of confidence in tackling the psychosocial aspects of care, with a tendency to prefer dealing with the more mechanical aspects of low back pain.¹⁵

It is possible, therefore, that the relatively weak treatment effects may in part be a consequence of difficulties in implementation rather than the effectiveness of the treatments.^13,16 Therefore, there is a need for resources to help clinicians with clinical practice implementation if the goal is to continue to advance PiP. The purpose of this Perspective is to introduce the PiP Consultation Roadmap as a framework designed to enhance the effectiveness of clinical management.

The PiP Consultation Roadmap

Qualitative studies of trainees in pain management/PiP trials^17–19 indicate that the principal challenge is not only what to do but how to do it, with the latter having more clinical practice ramifications. The PiP Consultation Roadmap is offered as a way of bridging the gap between assessment and intervention, which in our view often seems to be a challenge in clinical practice. Its development has been informed by issues that have arisen during training (mainly PTs) in PiP for research trials and focuses on the clinical issues that have arisen both during the actual training and the subsequent mentoring of clinical cases. The central importance of communication style and content was highlighted in the companion paper² and aligns with the 4 specific recommendations.²⁰ These considerations have been paramount in the development of the Roadmap:

1. Establishing a therapeutic climate and encouraging open communication underpin the successful identification of patients’ beliefs and expectations.

2. Addressing specific concerns and clarifying misconceptions at the outset will facilitate the development of an agreed upon plan of action.

3. Providing all patients with a credible but simple explanation of the difference between acute and chronic pain, the importance of central pain mechanisms, and the development of disability.

4. Providing the explanation using language and terminology that patients understand ensures that it shapes their beliefs and expectations and optimizes their pain coping strategies.

The PiP Consultation Roadmap is intended as an integrative, rather than additive, approach to traditional PT that increases treatment efficiency and may also increase patient buy-in. The consultation is represented as a staged encounter between a driving instructor (the therapist) and their patient (the person struggling with chronic pain and its effects). However, it is important to contextualize the PiP Consultation Roadmap as a guiding framework and not as a fixed process. Although the Roadmap offers a path to self-management, each journey must be individualized (ie, tailored) since patients differ in both the nature and complexity of the obstacles they must overcome. Moreover, progress may require revisiting and reconsidering previous stages.

The stages of the PiP Consultation Roadmap are illustrated in Figure 1 and as a guiding framework for a patient case example in the Supplementary Material. In addition, core elements of the implementation strategy are presented in Figure 2. Finally, the Purpose, Behavioral Change Techniques, and Mechanisms of Action are described in the companion paper.²

Figure 1.

The PiP Consultation Roadmap. PiP = psychologically informed practice.

Figure 2.

Stages of the PiP Consultation Roadmap. PiP = psychologically informed practice.

Stage 1: Initiating the Conversation

People consulting with pain-associated problems may be unclear about why their pain is persisting or what to expect from the consultation.

Example: Patients with chronic pain can become disheartened, possibly confused, or even possess anger as a consequence of their previous health care consultations.

The principal objective of the first Roadmap Stage is to help the patient understand that reactivation, and the recovery of function, will be addressed using a patient-centered approach from the outset, ie, prior to eliciting a detailed pain history. The role of the clinician is best understood as that of a coach, beginning with shared “detective work” and leading to improved pain coping strategies implemented by the patient. In turn, the patient then has ownership of the change and is responsible for subsequent actions (or behaviors) to promote reactivation.

The importance of establishing an appropriate therapeutic climate cannot be overestimated.²¹ Having introduced themselves and minimized formalities, the clinician will need to offer reassurance about their familiarity with chronic pain and its effects. A hypothetical conversation should begin with the clinician, asking the patient how they would like to be addressed and inviting the patient to clarify the nature of their problem and finish with the clinician ensuring they understand what has been conveyed by the patient (see Fig. 2). Finally, remember that the main purpose of this initial contact is to develop a therapeutic relationship or “rapport,” not to educate them in the nature of chronic pain and its management.

Stage 2: The Starting Point

It is helpful to explain what you can and cannot offer and why you are recommending that the patient consider different ways of coping with pain.

Example: Many patients arrive with expectations of pain relief stemming from a multitude of sources. Unfortunately, these expectations can be unrealistic which is why it is important to explain that a careful assessment of their pain experience is vital.

The overall objective of Stage 2 is to clarify the context of the consultation as a precursor to facilitating patient-centered management.²² The clinician needs to ensure that there are no misunderstandings about the purpose of the consultation, explain why you are requesting initial clarification as a way of moving forward, acknowledge that they may have been asked for details previously, and elicit their consent to proceed. If appropriate, you may wish to reassure your patient that you will then be examining them. They need to be encouraged to give you as full a picture as possible.

There is a range of approaches to eliciting information—from automated records to sophisticated psychiatric encounters.²³ However, in clinical practice, the clinician often starts with little more than a referral requesting a consultation for a named clinical condition, with little accompanying detail. Much of the published literature focuses on specific detail needed for diagnostic purposes and how the report of symptoms aligns with physical signs, but it is necessary to obtain the person’s own account of their pain, its treatment, and any other illnesses currently of concern to them. Particular attention should be paid to any distress or misunderstandings, which may have arisen in their encounters with previous clinicians. However, although an appropriate level of empathy is important, remember that your role is as their clinician—not an advocate—and your prime objective should be to help them to focus on the development of adaptive coping strategies. The emotional impact of previous consultations is hard to evaluate, but a strong sense of injustice may have become associated with pain intensity and pain behavior.²⁴

Finally, it is important to confirm a person’s preferences and value on the range of possible goals considered. Not all goals may be immediately achievable, but even modest progress toward them may serve as key milestones and important encouragement. Remember that effective communication has multiple benefits such as: enabling patients to understand complex medical terms and concepts in lay terms, increasing patient satisfaction, facilitating participation in the consultation, and promoting trust.²⁵ PiP assumes a basis of careful biomedical evaluation; however, its specific focus is on the perception of pain and its impact on function, well-being, and work/social participation, and the eliciting of information must be handled with cultural and sociodemographic sensitivity. Relatedly, the goal is to deliver evidence-based approaches to managing pain, but patients often derive comfort from past treatments. Often, these treatments are passive in nature. To this end, passive modalities earlier in treatment may benefit some; but, long-term, the goal should be evidence-based approaches to achieve long-term benefits.

Stage 3: Route-Finding

You are giving a strong signal not only of detective work, but also adopting a patient-centered approach.

Example: Patients who are expecting and seeking passive treatment need persuasion as to the value of learning and adopting more effective coping strategies.

This is an important stage since, with the development of shared decision-making, the patient should have become progressively self-reliant. However, you should begin by offering a summary of your initial appraisal, inviting corrections, and offering clarification. Discussing individual goals and their potential obstacles is where the therapeutic work really begins. Success depends on the translation of general, sometimes over-ambitious or unrealistic goals, and breaking them down into specific targets for behavior change (which from your clinical experience you consider to be achievable).²⁶ As previously stated, it is important to invite the patient to contribute toward developing an initial plan from which a strategy can be developed, but a degree of fine tuning or adaptation later may be required.

Your role as a coach is now to help the patient develop a focused but flexible plan (inviting options for consideration rather than forceful persuasion of your own opinion). There are usually a range of possibilities which may merit consideration, but the goals must be both achievable and valued by the patient (if only as the means to an end), and in shaping expectations you may have to move the goalposts. Much is currently made of the notion of “acceptance,”²⁷ a useful counter, for example, to a repeated search for low probability outcomes (such as miracle cures). However, acceptance should not be confused with resignation or giving up. You need to ensure at least “qualified acceptance” of interim targets as a worthwhile way forward.

The strengths and weaknesses of various strategies can be discussed, and it may be helpful to offer alternative goals or ways of overcoming obstacles. However, remember that you must only offer suggestions for consideration. It is important to acknowledge the effort that the patient has made and to begin with a “win.” Initial success demonstrates recovery of some control over the pain, and getting started is more important than the extent of initial progress. Be sure to make note of any issues to which you may return.

Although the process of clarification may be therapeutic in its own right, it is helpful to make a distinction between treatment planning and its implementation. Indeed, funding of the consultation may require separate billing for the 2 components. Jurisdictions differ in the extent to which the number of sessions needs to be specified in advance or whether staged funding based on further clinical justification is required.

Booster sessions are emerging in the management of chronic pain conditions such as low back pain and osteoarthritis, and the option of additional booster sessions may have been built into the original agreement. A meta-analysis by Nicolson et al²⁸ found incorporating booster sessions with a physiotherapist increased therapeutic exercise adherence. However, the need for such sessions should be determined on an individual basis and care should be taken to avoid “mixed messages” regarding the therapist’s confidence in the patient achieving their goals.

So, if you have set the expectations within an appropriate therapeutic climate, both you and the patient will already have discussed when it is time to conclude the intervention. In parting company, you should acknowledge that dealing with chronic pain and its effects can be a considerable challenge and congratulate them on their achievement.

Stage 4: Vehicle Check

By this stage your patient—with your assistance—will have identified “good bets” in terms of valued behavioral outcomes and how they might be reached. This is a critical stage in which possible ways forward are jointly explored and potential obstacles to behavior change are identified.

Example: It is necessary to begin with how the pain is currently being managed, but patients may not initially understand the effects of psychosocial influences on chronic pain.

Before setting off on the journey, it is important to revisit each of the potential obstacles and how they might be dealt with. The initial distinction between clinical and occupational factors^29,30 can lead to further distinctions between individual versus system factors.³¹ In clinical practice, it is important to distinguish psychological factors (such as beliefs about pain, its impact on function, participation and well-being, expectations of outcome, and pain coping strategies) and social influences. Shaw et al.³² differentiated social influences into co-worker support and organizational support; partner/family influences; and wider societal influences such as social disadvantage.

Whether any such obstacles can be reasonably addressed or circumvented needs discussion in development of the proposed intervention. However, such obstacles may arise during the treatment process and only become evident when a sudden increase in pain intensity is reported or the patient reports difficulty in finding time to complete their new home exercise program. It may be necessary to modify the plan in light of further information (eg, from a pain diary) or a change in the patient’s context. (More detailed discussion of individual obstacles is presented in the next section.) It is important, therefore, to remind the patient that a degree of flexibility should be built into the plans due to unanticipated roadblocks since unforeseen difficulties often arise.

The role of significant others has been recognized since the earliest days of pain management. Clinical commentators have tended to emphasize unhelpful characteristics such as oversolicitousness (which was assumed to reinforce unhelpful behaviors) and possible secondary gain for chronic pain patients, in terms of obtaining support, but the major therapeutic focus was on the establishment of well behaviors or adaptive coping strategies.⁷

It is certainly appropriate to investigate how chronic pain has affected others and to discuss whether they might be involved in finding a way forward. However, this can be a matter of some sensitivity and the final decision must lie with your patient. If appropriate, you may invite the patient to suggest ways in which a partner or acquaintance is or could be involved and, if necessary, arrange to meet with the partner to explain the treatment rationale and answer questions. It is often helpful to share other patients’ experiences regarding this approach to rehabilitation. Similarly, you may wish to feed back the plans or progress you and your patient have reached to a referring agent or member of the team whose help you seek. However, the reasons for doing this should be explained and consent sought from the patient.

Hopefully, an agreed plan is now in place and the engine can be started but it is important to crosscheck with the patient that they are ready to set off. Offer encouragement and optimism (with a low-key sell) and remind them that progress is usually coupled with setbacks from time to time.

Stage 5: Checking Fitness to Drive

By now, the role of the clinician is evolving into more of a coach than a therapist who underlines each interaction with positive encouragement.

Example: However, unforeseen obstacles may now present themselves and it is important for the patient to lead the attempt to accommodate and circumvent these.

In gaining their “license” to embark on reactivation, your patient has had to gain an understanding of chronic pain and its effects; be willing at least pro tem to pursue an alternative to complete cure; and share in the development of a strategic approach to paced reactivation.

This PiP approach requires reconsideration of your role as a clinician (driving instructor). The PiP therapist must establish a therapeutic climate which helps the patient fully share their hopes and concerns, which permits the establishment of a shared approach. This communication involved is different from traditional biomedical therapy in that it requires explicit recognition of 2 sorts of expertise: that of the patient, in the way they have been affected by the persistence of pain, and the pain rehabilitation expertise of the clinician.

There are both strengths and limitations of self-reported pain ratings,^33,34 but they must not be adopted uncritically. The importance of the original “detective work”, clarified perhaps with use of a simple pain diary, will now be recognized because in considering the task of reactivation, you have now reshaped the task as one of identifying and tackling the determinants of behavior change.³⁵ Sharing their initial appraisal with the therapist, including challenges which have been identified, will enable the patient to obtain feedback on how best to proceed.

Unsuccessful treatment and an adverse impact on relationships with family, friends, and colleagues may increase the emotional impact of chronic pain with the passage of time. This may in part be a consequence of misdirected problem-solving,³⁶ and it has been found that reframing concepts in lay terms increases patient satisfaction, facilitates participation in the consultation, and promotes trust.²⁵ The clinician must establish agreement about which obstacles can be tackled initially, but if a focus on some of the issues proves particularly unwelcome or stressful, it may be sensible do defer consideration of them to a later date when some progress has been achieved. Some of the common difficulties that may need to be overcome are shown in Figure 3.

Figure 3.

Common obstacles within the pain-centered consultation.

However, these difficulties are only important to the extent that they pose significant obstacles to reactivation and may be lessened in their impact or even overcome as part of the reactivation process. If a satisfactory relationship has been established, and agreement reached on a plan of attack, then a basis has been established on moving forward with the reactivation plan and your trainee can assume charge of the vehicle.

Stage 6: Handing Over

The patient should now be seeing some results of their efforts and it should be emphasized that the change is a direct result of the skills they have learned and applied.

Example: Setbacks are to be expected and patients can become discouraged. They may need encouragement to continue with the plan that they have put into place, and further develop coping skills they have already mastered (albeit sometimes with a pause or slight change in application).

The “hand over” has in fact been a gradual process, initiated by the patient-centered agenda developed throughout the Roadmap. Hopefully, the nature of a patient’s involvement, clarified impact of their chronic pain, and development of a way forward will have provided them with increased confidence to make changes, and also an understanding of how to implement such changes.

Now, your task as a clinician-coach is to support their plans, reinforce their ownership of and responsibility for the decision-making process, and to embed self-management. You must make it known that, although you will offer further guidance if requested (as the reactivation process progresses), progress is a result of their own efforts. If requested, further assistance should be offered on new options that they may like to consider, but still, the decision is theirs. Your stance should be one of guarded optimism. It is important to stress the motivating impact of achieving goals and to remind patients that if they encounter setbacks, they should try to learn from them, and plan for adjustments to deal with further obstacles.

Each session should begin with their appraisal of progress and discussion of any further suggestions offered by the patient. At early stages, your encouragement is likely to be important but as the change process gathers speed, you need to help them rely on self-appraisal. You have now prepared the patient to drive the car and proceed with the reactivation program.

Stage 7: Continuing/Ending the Journey

Your work as a coach is nearing an end. It is important at this stage to emphasize your encouragement of patient progress and your confidence in their ability to self-manage their pain condition.

Example: Naturally, many patients become dependent upon their therapist to manage their pain condition. In such cases, a booster session is often offered as part of their therapy, thereby “phasing out” therapist dependence.

By now, your patient should become increasingly competent and confident in their journey through the PiP landscape. You may need to remind them once again to expect temporary setbacks that they can learn from and perhaps settle for interim targets. They need to continue to accommodate changes in the environment—whether as a consequence of their more effective coping strategies, or independently of them. Prior to leaving the vehicle, you should carry out a final crosscheck of any residual issues that they would like to discuss with you. As you approach the agreed end to therapy, it is appropriate to ask them to reflect on the changes they have made, how the process has affected them, and what they understand to be the “take-home-messages.”

Stage 7 is an important milestone as the patient is embarking on an independent journey of self-management. Usually this will be the “end of the road”, although further specialized care may be clinically indicated. However, it is to be hoped that the use of the PiP Consultation Roadmap will assist in the delivery of patient-centered care and in the optimization of clinical outcome.

Summary and Conclusions

During the past decade, PiP has been increasingly featured in the management of musculoskeletal pain conditions. Its particular focus on psychosocial obstacles to recovery, or optimal function, is now well established and aligns with the development of patient-centered medicine. However, despite encouraging results in research studies, there have been problems with clinical implementation.

The PiP Consultation Roadmap is a clinical implementation guide that offers a structured approach to clinical consultation and also encompasses the capacity to tailor communication and interventions specific to each patient. The 7 stages of the Roadmap are designed to assist in the establishment of effective self-management using a patient-centered approach from the outset (see case example in the Supplement). The emphasis on developing a therapeutic relationship—to maximize the patient’s involvement in planning, decision-making, and the use of effective coping strategies—will increase their likelihood of achieving both competence and confidence in managing chronic pain and its effects. The PiP Consultation Roadmap is, in essence, a recipe for action, with the principal objective of facilitating behavior change (whether in dealing with specific clinical concerns such as fear of movement or in tackling obstacles such as returning to the workplace).

It is hoped that the establishment of effective communication suggested in this Roadmap might serve as a template for future development in clinical consultations, such as a focus on positive health targets³⁷ or the development of a clearer focus on work as part of the consultation.³⁸ In-depth guidance of such advancements is beyond the remit of this Perspective, though we provide some suggestions for the exploration of change opportunities (Fig. 4). It is hoped that this analysis of the consultation, and its associated implementation plan, will establish a firm foundation for more successful encounters for both the patient with pain and the clinician in current practice.

Figure 4.

From obstacles to opportunities for change.

Author Contributions

Concept/idea/research design: C.J. Main, C.B. Simon, J.M. Beneciuk, C.M. Greco, S.Z. George, L.A. Ballengee

Writing: C.J. Main, C.B. Simon, J.M. Beneciuk, C.M. Greco, S.Z. George, L.A. Ballengee

Data collection: C.J. Main, L.A. Ballengee

Project management: C.B. Simon

Consultation (including review of manuscript before submitting): S.Z. George, L.A. Ballengee

Funding

The preparation of this Perspective was funded in part by the National Institutes of Health (K76AG074943). The funder played no role in the writing of this work.

Disclosures

The authors completed the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported no conflicts of interest.