Psychologically Informed Collaborative Conversations for patients in pain

Patients living with pain are set to benefit from patient-centred consultations which address both the physical and psychological components of pain, following a successful trial. The NHS's Health Innovation Network and St. George's and Kingston Hospitals have supported the development of Psychologically Informed Collaborative Conversations (PIC-C), an innovative training and supervision course for allied health professionals.

With up to half of UK adults experiencing pain, PIC-C aims to create a 'therapeutic alliance' between patients and the clinicians who treat them. The course – co-designed by people living with pain and in partnership with the Physiotherapy Pain Association, St George's and Kingston Hospitals Chronic Pain and MSK teams – has delivered promising initial results and evidence of real changes in practice. All clinicians in the pilot reported the training reduced their anxiety and increased their confidence in using psychologically informed techniques with their patients. Ninety-six per cent reported that the training had increased their compassion for others as well as overall work satisfaction and resilience. Further positive impacts were observed in reported work satisfaction and reductions in perceived fatigue.

Carole Robinson, who is a volunteer patient representative in Kingston Hospital and was a medical practice manager for the NHS for 44 years, helped co-produce PIC-C. She said: 'I have lived in pain now for 25 years, so it's been a long, long haul. It's a constant battle really, physical discomfort as well as mental and emotional side effects. Nobody asked me how I was managing or coping but I know now that there will be somebody around who will be thinking about that right from the start. Hopefully PIC-C is going to change the patient/clinician relationship dramatically. I hope that this is going to be a real eye-opener for people to be able to discuss how they feel and how it's affecting them.'

Health Innovation Network PIC-C Project Lead Amy Semple said: 'Physiotherapists told us that PIC-C fills a known training gap. When pain persists it often leads to increased psychological distress. We know that many physios don't get the specialist training for this so PIC-C gives them vital skills and confidence in developing alliances with patients in consultations to help generate positive change.

'The unique selling point of PIC-C is its focus on experiential learning – learning through doing – and it has protected supervision and reflection time built into the course to really help embed the learning and discuss complex cases with colleagues. We urge commissioners to have a look at the resources on our website and get in touch to see how it could be delivered in their locations.'

We also heard from Dr Anna Mathieson, Highly Specialist Clinical Psychologist, Chronic Pain Self Management Team, St George's.

What's new about the approach?

The Psychologically Informed Collaborative Conversations (PIC-C) training package was jointly designed and delivered by a Highly Specialist Clinical Psychologist and a Highly Specialist Physiotherapist working in pain management. The project team behind the training package was made up of Multi-Disciplinary professionals with expertise in pain management, and patient representatives living with persistent pain. The patient representatives were experts by experience and were directly involved in designing teaching materials for the training programme.

What makes PIC-C more unique is that the training involves a number of weeks of teaching sessions followed by a number of weeks of supervision sessions. The teaching and the supervision sessions were facilitated by the Highly Specialist Clinical Psychologist and Highly Specialist Physiotherapist and focused on models and skills for having collaborative and compassion conversations in consultations with patients. The training provides an opportunity for learning to be consolidated over the longer term in comparison to most other training events given the length and structure of the training programme. 

Regular supervision sessions allowing for time to reflect on clinical practice is relatively new in Physiotherapy in comparison to Psychology. PIC-C allows for dedicated time to reflect on cases with peers and professionals with expertise in pain management, and supports the development of enhanced communication between services and professionals, which ultimately can lead to improved patient experiences through better joined up working. 

What do the patients think of it?

As yet we haven't been able to directly assess the impact of the training on the experiences of people living with pain, but anecdotally we have had a lot of feedback that the training has helped healthcare consultations to feel more compassionate and collaborative. Our outcome measures showed some fantastic improvements in staff wellbeing, including increased confidence, resilience and compassion for others which we hope to eventually be able to show has also had a wider positive impact on patient experience.

And what about the other clinicians – are you pushing at an open door in terms of the understanding that conversations need to be psychologically informed?

At the start of the development of the training package, focus groups were conducted with Physiotherapists to ascertain their views and experiences of psychologically-informed practice. The focus groups provided clear feedback that there is a strong desire from clinicians to be more psychologically informed in their practice, but that they perceive there to be a gap in their training in terms of feeling able to develop and utilise these skills. The PIC-C training therefore provides an opportunity to learn more about the theory behind psychologically-informed practice, as well as an opportunity to try these skills in practice and reflect with peers and supervisors on their skills development through supervision.

Is there a danger that addressing psychological aspects becomes mostly about accepting and tolerating pain, at the expense of finding physiological 'cures'? 

It is understandable that this could be a concern, however in many ways it is actually the opposite. Supporting healthcare professionals to address biopsychosocial needs as a whole can help professionals to look at overall wellbeing and consider emotional and physical health together rather than separately. A truly biopsychosocial approach can in turn allow people living with persistent pain to discuss and consider all options available to them in terms of managing their long-term condition, whether that is medical interventions or self-management options. Taking a whole-person approach to a consultation can allow the person living with persistent pain to build a toolbox of skills and support opportunities which would hopefully lead to an overall improvement in their quality of life, through feeling more supported and in control of their own wellbeing.  

What still needs to change?

Our challenge now is finding the best option for how to move forward and grow the training further. We are fortunate to have many different options ahead of us and so the project team are in the process of making a plan for the best next steps. 

A training programme such as PIC-C that is delivered over a number of weeks requires a larger time commitment than most training, and so another challenge can be gaining the support of organisations to free up their staff in order to attend all sessions. A real strength of our pilot delivery of PIC-C was that despite being delivered in the middle of the pandemic, the attendees were given protected time to attend the sessions. We hope that the outcomes showing improved resilience, confidence and compassion in those who have completed the training will encourage organisations to host the training in their areas for the benefit of their staff, which will hopefully lead to improvements in patient experiences.

- Read the HIN's report on Psychologically Informed Collaborative Conversations (PIC-C) on this link. Watch a short video here.

Find much more on pain in our archive.