5 minutes with… Dr Zoey Malpus

The Chair of the British Psychological Society Division of Clinical Psychology's Pain Network, Dr Zoey Malpus, was among three consultant clinical psychologists who contributed to the Royal College of Anaesthetists Core Standards for Pain Management Services document. Malpus, alongside Neil Berry and Dr Hannah Connell, set out standards and recommendations for psychologists working in chronic pain services. She spoke to us about their involvement and the future of psychology's role in pain management.

What's your own personal take on pain and pain management?
That it is entirely normal to become disabled and distressed when you are in severe pain each day. It makes complete sense to avoid activities that might make your pain worse or to try to make the most of a good day, cramming in far too much and probably triggering a flare-up of your pain, because you don't know when you will next have another good day. Unfortunately these commonsense coping strategies have the unintended consequences of exacerbating persistent pain, causing further physical deconditioning leading to even more frustration and hopelessness. I see my role as helping people to discover the unintended consequences of the ways that they have been managing their pain. In many ways this approach is very similar to the ways I was taught to treat panic attacks as a junior psychologist, and you can get the same 'light bulb' moments that make the work so rewarding.

What did you emphasise in the core standards and why?
Current guidelines recommend psychologically based pain management as the treatment of choice for people with persistent pain that has a significant adverse impact upon quality of life and physical, psychological and social functioning. This is why psychologists are core members of multidisciplinary pain teams, because they ensure that psychological and social factors are properly assessed, formulated and effectively treated.

In addition to generic professional standards for psychologists, there were several key points that we wanted to emphasise for pain psychologists: appropriate pain-specific core training and clinical supervision; the importance of evidence-based assessment and therapy; ensuring that job plans and caseloads for psychologists working in pain services allow time for both direct and indirect ways of working, in recognition of our key role in supporting other members of the pain team to work in a psychologically informed manner; and including all practitioner psychologists, emphasising core knowledge, skills and competencies for working in pain services, rather than stating that it should only be clinical psychologists.

A psychologically based approach does not mean that the pain is 'all in the head' or that effective therapy will cure the pain. Most of my time is spent sharing the latest scientific research about the neurophysiological basis of persistent pain, the synaptic plasticity that causes pain to accelerate and 'wind up' over time.

Unfortunately when I usually meet people, they will have had pain for years and there is no longer any hope of an effective cure. However, we can show people ways to gradually rebuild their strength, fitness and flexibility, show them how to manage their natural stress reaction to their pain so that they can rebuild their lives again, despite their pain. This means that whilst people will not be pain-free they can lead fulfilling lives that are definitely worth living. Acceptance seems to be very important in terms of being able to carry on with meaningful activities even when pain is there in the background.

What does the future hold for psychologists' role in pain management?
Most recently I have become excited about compassion-focused therapy, the work of Professor Paul Gilbert and colleagues. It is a third-wave psychological therapy that draws upon evolutionary psychology and Buddhist principles. It seems to have a particular importance for pain management because of the role of soothing the nervous system by activating our compassionate motivational states. Self-kindness appears to be key to acceptance, to engaging in activities and letting go of the need to control pain. I think this will be a key development for a subgroup of people with pain who are 'strivers', who refuse to slow down until they get burnout. Compassion in Pain Management Programmes was the title of our recent British Pain Society conference in Manchester in September 2015. This stimulated lots of collaborative ideas for further research, and we hope to be publishing further work in this area soon.