An assessment of 20 patients’ collages before and after an outpatient pain management programme.

[i]	Dr. Gillian Moore-Groarke, Consultant Psychologist Dr. Jack Barrett, Consultant Anaesthetist, and Pain Specialist

Introduction

Many patients often have a difficulty verbally expressing their opinions on pain. The use of a collage is a powerful way of representing the kaleidoscope of emotions that patients with chronic pain feel, before, and after completion of a pain management programme. Collages are widely used in art therapy, and afford patients to view their emotions in an objective fashion with their therapist. Working with creative therapies also encourages the patient to be creative. When in pain or severe psychological distress this aspect of a patient’s personality is often dormant and contributes to further reactive symptomatology.

The patients are asked in the 4th week of the programme by the psychologist Dr. Moore-Groarke, to put together individually 2 collages.

(a) Their perception of pain before the pain management programme and

(b) Their perception of pain after the course.

They are asked to include words or visual images that in someway represent their individual perception of their pain. As more and more patients complete the programme certain patterns and similarities between the collages have been emerging. All in all 40 collages have been examined in this study, 20 collages before the programme, and 20 collages after the programme.

Patient cohort

The patients who completed a 4 week, 3 days a week pain management programme out patient community based programme participated in the study. The psychological input into the programme is 3 hours per week.

The cases of pain included 9 back pain as a result of a road traffic accident, 9 back pain due to work related accidents with two patients suffering from fibromalgia.

Equal numbers of male and female

Summary of patients

Equal number of male and female patients took part. 5 of the males suffered back pain, 5 experienced road traffic accident and more presented with fibromalgia. The average age of males was 35.

In the female group 4 had back pain. 4 had injuries due to road traffic accidents and 2 presented with fibromalgia. The average age was 33.

50 more males than females, 4 vs. 2, were working full-time. Equal proportions of males and females worked part-time, and more females did not work as oppose to males, 7 vs. 5.

Analysis of the collages

The following are the 10 most used words found in the before collages.

Pain Stress Anger Depression Fear Worry Tiredness Out of control Distressed Loss of sleep

In the after collages the following are the 10 most frequently used words.

Relaxation Positive outlook Increased confidence Better motivation Choices Responsibility Pacing Goals Coping Active

The 10 most common pictures used in the before collages.

Pictures of people in pain Crashed cars/lorries or somebody falling Overweight Person Watches representing time Pictures of x-rays Pictures of injections Pictures of tablets Pictures of doctors Pictures of people in wheelchairs Pictures of beds

The 10 most common pictures/images in the after course collages

Pictures of happy faces Pictures of flower/candles Healthy weight people Pictures of people relaxing Pictures of people walking/exercising Pictures of happy couple/family Holiday locations Pictures of people driving Pictures of people shopping Pictures of people working

Conclusions

It is important to stress that such a study is very much a pilot study but as we progress in the number of programmes we run the patterns shown in this study regarding the psychological shift in patients emotions and perceptions of pain is similar.

There is no significant differences for male or female patients and we are pleased that much of the multi-disciplinary approach to pain management that we teach on the programme are reiterated in the collages.

Anger and fear are the most significant emotions we see in patients both at assessment stage and in the first half of the programme. We try to teach patients the importance of relaxation, motivation and the language of pain in terms of choices and responsibilities they have regarding their own thought processes. Pacing and goal setting was also numbers 7 and 8 respectively in the after collages.

The picture collages also highlighted other aspects taught on the course like reducing medication, time and weight management, exercise programmes and addressing family needs where appropriate. The programme does run a family day if patients desire.

Another interesting observation of the collages was the change in the use of colour by the patients in their before and after collages. Generally patients presented words and images in black while, grey or brown colours in the before collages, while the choice of colour was more varied in the after collages. This was a further confirmation of change in mood and patient attitude. It also begs the question that perhaps there may even be a role for colour therapy in treating negative emotion in patients with chronic pain. The literature on depression most definitely highlights the benefits of colour therapy for enhanced psychological well-being.

The patients are also encouraged to be proactive and take an active role in their own recovery and we are pleased to see this in their collages.