Application of the Transtheoretical Model in Chronic Pain

Having chronic pain patients take an active role in the management of their conditions is a process, according to Rebecca Curtis, ACC. And, perhaps no one knows that better than the former "difficult patient" herself.

Curtis, who gave a session directly before this current presentation (see Cure Me, or I Give Up: The Role of Acceptance in Patient Self-Management), became a patient herself after a car accident that broke her neck. She was eventually able to regain mobility but was left with a chronic pain condition affecting both halves of her body in different ways. After entering a psychosocial and behavioral therapy program, she was able to accept her condition and develop a new regimen that helped improve her quality of life. She is now a healthcare provider working with chronic pain patients.

The presentation, "Application of the Transtheoretical Model of Change in Coaching Chronic Pain Patients," discused the Transtheoretical Model in coaching patients. Curtis highlighted methods of engaging patients in creating their own management programs. The transtheoretical model suggests that it is unrealistic to expect patients to make a change if they're not ready to make a change. It focuses on self change as a stage process.

The stages are: precontemplation, contemplation, preparation, action, and maintenance. Precontemplation is the stage where many of the cons of changing a behavior still outweigh the pros for the individual. The patient may be defensive, disinterested in help, or discouraged. Physicians should respond to patients in this stage with empathy and ask open-ended and non-judgmental questions. Persuading may be ineffective here, she said.

The next stage—contemplation—is when the patient is at the point where he or she may make a change in the next 6 months, she said. The pros start to outweigh the cons, and the patient starts to think about the problem. Though still ambivalent, he or she may be willing to learn. What works will in this stage from physicians is to provide education, social, and emotional support.

In the preparation stage, the patient is usually getting ready to make the change within the next month. The pros greatly outweigh the cons. The patient may have made at least one attempt in the past year and is setting goals and expectations for him or herself. Here, physicians can provide praise for the patient’s attempts to change, assist in goal settings, discuss a plan of action, and identify potential pitfalls. They can also encourage support from others.

The action stage occurs when the patient is making the change. Here, he or she is engaging will power and developing a sense of autonomy and improved self-efficacy. They may also have feelings of guilt and feelings of limited freedom. This is a very stressful stage, Curtis said. "It’s important for them to feel like change is possible," she said. Physicians can help these patients focus on the benefits of change and discuss strategies for continued success to prevent relapse.

During the last stage — maintenance -- the patient has been performing the behavior(s) for at least 6 months. Here, the patient reminds him or herself of the great progress they have made, but also continues to reformulate the rules of their life. The patient also acquires new skills to deal with their life and anticipates situations where a pain flare may occur and uses techniques to control it. Physicians can help by providing positive reinforcement.

Rather than pushing patients to take action, Curtis said it's important to try and encourage people to progress from one stage to the next. “It doesn’t take a long time,” Curtis said. “Just listen to what stage they are in. Then help them move forward.”