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Occupational Therapy in Mental Health
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Addressing Self-Stigma in Fibromyalgia Using Pain
Neuroscience Education: An Occupational Therapy
Case Study
Christine Davis & Marian Gillard
To cite this article: Christine Davis & Marian Gillard (2022): Addressing Self-Stigma in
Fibromyalgia Using Pain Neuroscience Education: An Occupational Therapy Case Study,
Occupational Therapy in Mental Health, DOI: 10.1080/0164212X.2022.2149666
To link to this article: https://doi.org/10.1080/0164212X.2022.2149666
© 2022 The Author(s). Published with
license by Taylor & Francis Group, LLC.
Published online: 25 Nov 2022.
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Addressing Self-Stigma in Fibromyalgia Using Pain
Neuroscience Education: An Occupational Therapy
Case Study
Christine Davis
a
and Marian Gillard
b
a
Department of Occupational Therapy, St. Croix Regional Medical Center, St. Croix Falls, WI, USA;
b
Department of Occupational Therapy, Baylor University, Waco, TX, USA
ABSTRACT
The symptoms of fibromyalgia can be misperceived because
they are often visibly undetectable, thereby leaving persons
with fibromyalgia exposed to others’incorrect understanding
of their experience and physical capabilities. Persons with
fibromyalgia may experience stigma, when nobody under-
stands the condition or how it affects their daily occupations.
This retrospective case study describes how occupational ther-
apy, as part of a biopsychosocial and multidisciplinary team
approach, can use pain neuroscience education as an effective
treatment strategy for fibromyalgia and discusses the benefits
of an educational approach to improve our understanding of
fibromyalgia, as well as decrease self-stigma and increase
occupational performance.
KEYWORDS
Occupational therapy;
fibromyalgia; self-stigma;
pain neuroscience
education; occupational
performance
Introduction
Preparing the occupational profile of a client improves the understanding
of the individual’s illness experience, including stigma attributed to certain
health conditions. An occupational profile initiates an occupational thera-
pist’s understanding of the client’s life history related to their experiences,
occupational roles, values, and needs (American Occupational Therapy
Association [AOTA], 2020). By understanding the client’s experience, we
can discern how an illness affects the client and may better comprehend
the stigma they experience.
This study explores the experiences of a person with fibromyalgia (FM)
named June (pseudonymized for anonymity) and her improved results after
interventions using Pain Neuroscience Education (PNE). June was referred
to occupational therapy by a rheumatologist to address her concerns about
FM’s impact on her daily life. When the occupational therapist (OT) met
CONTACT Christine Davis Christine_Davis2@baylor.edu Department of Occupational Therapy, Robbins
College of Health and Human Sciences, Baylor University, One Bear Place # 97303, Waco, TX 76798, USA.
ß2022 The Author(s). Published with license by Taylor & Francis Group, LLC.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives
License (http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction
in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way.
OCCUPATIONAL THERAPY IN MENTAL HEALTH
https://doi.org/10.1080/0164212X.2022.2149666
June to gather her occupational profile, she was vocal, honest, and disheart-
ened when discussing her life story. The OT noted her fidgeting hands and
teary eyes as she spoke of the trauma and struggles in her life, underscoring
the psychosocial impact of the disease. The OT observed her optimism while
setting her goals, as well as her dejection after identifying her current level of
performance.
Research on occupational therapy applying concepts of neuroscience edu-
cation in practice is scarce, yet there has been moderate evidence supporting
the use of neuroscience education as an intervention for people experiencing
chronic pain diagnoses such as FM (Snodgrass & Amini, 2017). PNE as an
occupational therapy intervention is supported by the AOTA’s(2021)pos-
ition statement on the role of occupational therapy in pain management.
The position statement highlights PNE as an intervention strategy to support
the achievement of a client’s occupational therapy goals as was used within
this occupational therapy case example. Our case study also explores the use
of a specific educational strategy in conjunction with traditional occupational
approaches, and if such a strategy can reduce the effects of self-stigma and
decreased occupational performance as perceived by a person with FM.
Understanding pain
Chronic pain is often viewed as a physical condition, which results in other
unacknowledged types of pain that fail to fit this normative expectation.
Health care providers often misdiagnose the source of other rarely detected
pain experiences, such as FM, and assign a physical diagnosis to a neuro-
physiological condition. When FM is deemed a physical condition, it may
become categorized as an observable disability. Perceiving pain as a phys-
ical manifestation of underlying pathology causes stigma when the meas-
ures to reduce or relieve the physical condition do not ensure pain relief.
When symptoms are not evident, chronic pain conditions may be viewed
as invisible illnesses, causing stigmatization because these infirmities rarely
fit with the typical views of Western medical science on pathology, and
thus, may not be observed objectively (Cohen et al., 2011).
Pain is a subjective experience that is unique to each individual. The
International Association for the Study of Pain (IASP) (2020), defines pain as
“an unpleasant sensory and emotional experience associated with, or resem-
bling that associated with, actual or potential tissue damage”and includes add-
itional notes to support understanding (Raja et al., 2020,p.14).Experiencing
pain which is typically associated with tissue damage, without any attributable
injury or physical changes, can be frustrating and confusing not only for the
individuals with pain, but for individuals trying to understand or empathize
with their loved one’s pain experiences. When an individual with chronic pain
2 C. DAVIS AND M. GILLARD
does not receive support or empathy from their family and friends, and pos-
sibly their health care provider(s), it can further impact their mental health
and occupational performance. Therefore, all healthcare providers involved in
the care of clients with pain, including OTs, should share a common language
and educate clients on how pain works to increase independence and under-
standing of the condition (Eneberg-Boldon et al., 2020).
Fibromyalgia
Persons with FM often experience pain regularly, without any visible, exter-
nal symptoms, causing the disease to be labeled as an “invisible illness”
(Armentor, 2017). According to the American College of Rheumatology
(2019), FM affects 2–4% of the US population and is a neurological health
condition characterized by widespread pain and weakness. People with FM
experience symptoms such as fatigue, decreased thinking capacity and
memory, and poor sleep. Furthermore, people with FM may experience
migraines, anxiety, depression, digestive concerns, pelvic pain, and other
health issues (American College of Rheumatology, 2019), which may be
overlooked due to a lack of a physical manifestation.
As a controversial condition, FM often creates social stigma, primarily due
to the lack of an explainable pathology. If health care providers struggle to
understand the underlying pathology of a client’s symptoms, it may result in
the stigmatization of persons with FM, because the disorder remains incom-
patible with the existing conceptual biomedical framework. These effects
extend to society at large, embedding the stigmatization of persons with FM
into our very culture and perceptions of pain (Cohen et al., 2011).
Applying a biomedical framework to diagnose and treat persons with FM
will not explain their painful symptoms, and the limitations imposed upon
self-care and daily activities. Waugh et al. (2014) discuss how the invisibility
of chronic pain creates a negative stereotype of disability, dependency, and
apathy, thereby forcing clients with chronic pain to “justify and defend their
experience, often leading to feelings of invalidation”(p. 550e2). When a per-
son’s experience is not validated by their health care provider, it may cause
them to question their own pain experience. Health care providers and the
general population may reduce such individuals’pain experience and limita-
tions to an inaccurate objective representation, based on their perceptions,
denying the latter their own identity and agency.
Stigma
The relationship between pain and social stigmatization originates from the
health care provider’s need to find a physical cause for pain. De Ruddere
OCCUPATIONAL THERAPY IN MENTAL HEALTH 3
et al. (2016) found that the inability of an observer (such as a health care
provider) to connect a person’s pain experience with a physical cause, often
leads to stigmatization and social exclusion. If the health care providers
employ a biomedical perspective and find no physical injury or illness, they
focus on diagnosing a mental health issue instead of a physical concern
(Cohen et al., 2011). The resultant stigma only serves to exclude the person
who experiences pain from others, by replacing their actual identity with a
virtual or perceived identity related to their pain experience (Goffman,
1997); Goffman explains that stigma can isolate a subject from others within
their social domain. Health care providers’failure to understand the connec-
tion between the biological, psychological, and social aspects that intersect
within the pain experience worsens the situation. Unable to make these
necessary connections, patients feel that no one understands them and hence
they feel guilty, believing that others perceive their pain as imaginary.
A person may internalize the outward beliefs and stereotypes of others
and develop conflicting beliefs about themselves, leading to self-stigma.
Corrigan et al. (2009) described the process of developing self-stigma as
having an awareness of the social beliefs and stereotypes about those with a
particular condition, agreeing with the beliefs and stereotypes and then
applying the beliefs and stereotypes to oneself. Perugino et al. (2022) noted
that many people who experience chronic pain also experience self-stigma,
and these numbers are similar to those who experience self-stigma related
to mental health conditions. A person who experiences self-stigma related
to FM, or other chronic pain conditions, may not understand their symp-
toms and may not have the confidence to confront the negative beliefs and
stereotypes related to their condition. They may apply the outward beliefs
of others, blame themselves for their symptoms, and experience other nega-
tive feelings, such as failure and worthlessness (Bean et al., 2022). To cope
with self-stigmatization and the symptoms they are experiencing, a person
may avoid certain activities and social gatherings (Bean et al., 2022), which
may negatively impact how they spend their time and organize their daily
routines. Waugh et al. (2014) found that pain self-efficacy was lower and
pain catastrophizing thoughts were higher in those experiencing higher lev-
els of self-stigma, which may be important to understand in the assessment
and treatment of clients with FM.
Self–efficacy
Self–efficacy signifies a person’s confidence in their ability to complete a
specific task or engage in a situation. It also affects the person’s consistent
participation in that task or situation (Bandura, 1977); “The strength of
people’s convictions in their own effectiveness is likely to affect whether
4 C. DAVIS AND M. GILLARD
they will even try to cope with given situations”(Bandura, 1977, p. 193). If
self–efficacy is low, a person may be diffident about completing a task or
avoid the task altogether. If self–efficacy is high, a person may persist
through the task or situation despite limiting factors. Successful perform-
ance strengthens self–efficacy beliefs; however, unsuccessful attempts lead-
ing to unfinished tasks diminish them (Artino, 2012).
According to Bandura (1977), a person’s self–efficacy can influence their
choice and participation in activities. Therefore, it is important that OTs
address self–efficacy, in order to improve clients’occupational performance.
Studies suggest that the experience of chronic pain has significant effects
on a person’s life roles and routines, forcing changes in the person’s every-
day life (McParland et al., 2011). Moreover, an individual’s beliefs are sig-
nificant in these altered life roles and routines. If a person with pain feels
unsure of an activity’s effect on their symptoms, they may become fearful
and avoid the desired activity.
Pain neuroscience education
Some healthcare professionals may have a poor understanding of the
multi-factorial pain experience which can cause decreased confidence in
their ability to treat chronic pain. Focusing only on the biomedical perspec-
tive is not sufficient to effectively treat chronic pain, and knowledge regard-
ing approaches that address all aspects of the chronic pain experience is
necessary (Johnson, 2019). The Australian National Pain Strategy (NPS)
recommends education and training in treating pain and encourages practi-
tioners to recognize stigmatization as well as help clients achieve societal
validation by including “neurobiological insights into the nature of
empathy”(Cohen et al., 2011, p. 1641). The World Health Organization
encourages health care providers to work as a team with their clients to
address pain (Kumar, 2007). Johnson (2019) included the recommendation
for care providers to work together “to co-create explanations about pain
and construct care plans that empower individuals to be active participants
in their treatment because it creates self–efficacy”(p. 6).
Pain neuroscience education (PNE) is an educational strategy that helps
clients, health care providers, and society at large to understand the biology
and physiology of the pain experience (Louw et al., 2016). Louw et al.
(2016) conducted a systematic review and found that PNE influences mul-
tiple factors. It can reduce the pain experience, catastrophizing thoughts,
and negative psychosocial factors, among others. Watson et al. (2019)
studied patients with musculoskeletal trauma who were preparing for sur-
gery and found that PNE helped reduce pain and anxiety, and also
increased self–efficacy.
OCCUPATIONAL THERAPY IN MENTAL HEALTH 5
Methods
Occupational profile
June is a 62–year–old woman who participated in occupational therapy
over the course of 5 months and 21 days (April 2019–October 2019), with a
total of eight visits. She was referred to occupational therapy by her
rheumatologist because of functional deficits associated with FM. During
occupational therapy treatment, she received interventions from a multidis-
ciplinary team comprising members from the Physical Therapy, Psychiatry,
Psychology, Podiatry, Pulmonology, and Rheumatology departments.
June was diagnosed with FM 10 years ago and had a significant surgical
history, including a surgery to relieve bilateral carpal tunnel syndrome and
right shoulder rotator cuff surgery. Her medical history includes lumbar
spine degenerative disk disease, hypertension, obstructive sleep apnea, and
chronic lower back pain. She had tested positive for Lyme’s Disease three
times in the last 8 months and was treated with a course of antibiotics.
Her reported symptoms include severe fatigue; joint, muscle, and liga-
ment pain; periods of forgetfulness; brain fog; anxiety; and depression.
Episodes of dizziness due to specific movements such as stooping to pick
up items; and numbness as well as tingling in hands, feet, and neck limit
her ability to engage in daily life tasks. She mentions a poor sleep routine
and considers morning her worst time of the day.
A complete occupational profile reveals that June was previously wid-
owed, and currently lives in a large, old farmhouse with her supportive
fianc
e, who is also disabled. June’s valued occupational roles previously
included that of a bus driver. Childhood trauma associated with her father’s
death when she was 12 years old, made her feel responsible for caring for
her 10 siblings, and later, being the primary caregiver for her mother. She
describes multiple traumas associated with her birth family, including the
destruction of a family home in a tornado and the loss of 10 family mem-
bers in a single year.
June reports that she is unable to care for her home, either physically or
financially, and describes many environmental challenges associated with
living in a large, old farmhouse. The water heater is damaged, and water
needs to be heated on a stove. Cooking and cleaning are difficult and con-
stricted by a decreased tolerance to standing. She struggles with dressing
herself and is afraid of falling while bathing and showering. She describes
vacillating from feeling emotionally numb to constantly crying.
If her symptoms were reduced, June wishes to resume caring for her
flower bed and vegetable garden. She wishes to go fishing, which she has
not done since her husband committed suicide six years ago. Her strengths
include support from her fianc
e, her desire to complete tasks such as
6 C. DAVIS AND M. GILLARD
gardening, cooking, and fishing, as well as loving and caring for her three
dogs. She was expressive during the occupational therapy evaluation pro-
cess and hopeful about occupational therapy helping her to meet her goals.
Data were gathered through semi-structured interviews, observations of
movement patterns including ease of movement with transfers, posture,
and stiffness when completing reaching and other functional movements
and four standardized measures. Measures were chosen based on informa-
tion gathered in the subjective portion of the initial evaluation and based
on measures used with those who experience pain to gain a better under-
standing of their pain experience. The retrospective single-subject case
study design underwent review from the Baylor University human research
ethics committee (IRB Reference #1919834). The committee determined
that the case study did not meet the definition of human subject research
according to the federal regulations 45 CFR 46.102e& (1). June provided
written consent for participation.
The Canadian Occupational Performance Measure (COPM) (Law et al.,
1990,2014) was applied to identify needs in the areas of self-care, product-
ivity as well as leisure and to develop goals accordingly. The COPM is a
client–centered and individualized outcome measure administered in a
semi–structured interview format which is used to identify occupational
performance concerns (Law et al., 1990,2014). Clients rate their perceived
performance with respect to desired activities and their satisfaction with
their performance in these activities. The ratings for performance and satis-
faction range from 1 to 10 with 1 indicating “not able to do at all”or “not
satisfied at all,”and 10 indicating “able to do extremely well”or “extremely
satisfied.”Ratings with higher numbers indicate higher performance and
satisfaction. The activities identified as important to the client became the
client’s goals for occupational therapy intervention.
The QuickDASH (Beaton et al., 2005)isan11–question outcome meas-
ure that gauges a client’s perception of their function and symptoms related
to upper limb musculoskeletal conditions. Although the QuickDASH is typ-
ically used to assess upper limb conditions, it helps understand quality of
life for clients with FM (Atao
glu et al., 2018). It also includes optional
modules with four questions each comprising a work module and a sport/
performing arts module. Clients rate each question on a 5–point scale with
1 indicating “no difficulty or limitation”and 5 indicating “inability”or
“extreme difficulty.”Ratings with higher numbers indicate higher disabil-
ity/symptoms.
The Pain Catastrophizing Scale (PCS) (Sullivan et al., 1995) is a 13-
statement measure which is used to gauge a client’s catastrophizing
thoughts and feelings regarding past pain experiences. The PCS considers
three different areas of catastrophizing thoughts including rumination,
OCCUPATIONAL THERAPY IN MENTAL HEALTH 7
magnification, and helplessness. Clients rate statements from 0- not at all
to 4—all the time, with a total possible score of 52. The higher the total
score, the more the client is catastrophizing the pain experience. Clients
with a score of 30 present a clinically relevant level of catastrophizing
(Sullivan et al., 1995).
The Pain Self-Efficacy Questionnaire 2 (PSEQ-2) (Nicholas et al., 2015)
is a two-statement self-rated measure indicating the client’s confidence in
their ability to work and lead a normal life despite their pain experiences.
Each statement is rated on a Likert scale from 0—“not confident at all”to
6—“completely confident.”Higher scores indicate higher pain self-efficacy.
Assessing self-efficacy is important to understand how a client is coping
with their pain.
Intervention
Pain neuroscience education
The decision to adopt PNE for this client aligns with the Occupational
Therapy Practice Framework: Domain and Process (Framework) (AOTA,
2020), which recommends using an educational approach to support the
participant’s progress. According to the Framework (AOTA, 2020), occupa-
tional therapy must promote health and wellness through treatment inter-
ventions that may restore, adapt, and promote participation in daily life
roles and routines. The use of PNE as an educational strategy is within the
scope of occupational therapy practices. Additional strategies used with
June included addressing sensory concerns, relaxation, energy conservation,
work simplification, pacing, and graded exposure. June also participated in
movement-based strategies including Blomberg Rhythmic Movement
Training
V
R
(BRMT), primitive reflex integration and neurodynamics of the
upper extremities to calm the nervous system, and she was properly
instructed to complete these in a home exercise/management program.
PNE was included along with these other interventions, and it allowed June
to better understand her pain and adopt required actions to address
her symptoms.
The therapist provided PNE using stories and metaphors and the “Why
You Hurt: Therapeutic Neuroscience Education System”(Louw, 2014) vis-
ual cards. The stories and metaphors chosen for instruction were related to
June’s reported experiences shared during the subjective portion of the
treatment session and prior knowledge from previous education provided
before intervention. Next, the therapist helped June make connections
between the education provided during the session and the effects of the
intervention at the end of the session. Both client-directed questions by the
therapist and therapist-directed questions by June allowed the therapist to
8 C. DAVIS AND M. GILLARD
understand if June could integrate the content and relate this information
to her own life. The knowledge was distributed in small amounts, during
sessions that were 10–15 min long, to allow June to grasp the information,
relate the learning to other treatment interventions, and build on concepts
she had learned in previous sessions.
Example of pain neuroscience education in an occupational therapy session
June was engaged in occupational therapy evaluation and treatment in the
outpatient hospital-based setting. At the beginning of the session, June pro-
vided subjective information regarding her status and areas of concern and
limitation, identified helpful strategies, and asked follow-up questions as
they arose. The therapist provided June with a metaphor describing the
nervous system as a living alarm (Louw et al., 2015) using the “Why You
Hurt: Therapeutic Neuroscience Education System”(Louw, 2014) visual
cards to apprize June regarding the nervous system’s function while relating
it to her life based on the symptoms and experiences she shared during the
session. June and the therapist then explored calming activities such as
rocking and manipulating a soft, slightly resistive fidget. These activities
included her stated sensory preferences and movement-based therapies to
provide preparatory activities through body awareness and calming input.
These activities were meant to allow her to return home to complete her
daily occupations with lesser influence of her symptoms by being aware of
the activities she could engage in as symptoms increased or decreased
before, during, and after task completion. We discussed the best times to
perform the activities in her daily schedule to help ease her symptoms and
allow her to complete more tasks that she wants to complete. At the end of
the session, June and the therapist connected the self-identified helpful
interventions to the education and developed a home activity program to
support continued occupational performance based on her expressed needs
and goals. The home activity program included recommendations on
when, what, and how to implement calming strategies throughout her day,
and calming BRMT
V
R
movements that June identified as calming and help-
ful to her during the session. June incorporated positive phrases and man-
tras into her daily routine as part of her home activity program to further
support the completion of home activities.
Future sessions were built upon the education from the initial interven-
tion session, and additional stories and metaphors were provided to illus-
trate necessary concepts related to her pain and symptoms in order to
improve occupational performance. June adopted other calming strategies
including visualization with breathing techniques, and movement-based
therapies such as BRMT
V
R
and upper extremity neurodynamics. In addition,
OCCUPATIONAL THERAPY IN MENTAL HEALTH 9
June employed energy conservation and positioning techniques to maxi-
mize daily activities such as washing dishes, laundry, meal preparation, vac-
uuming, and removing items from the dishwasher, as well as addressing
important personal goals that she had established.
Results
A retrospective single-case study design including pretest and post-test out-
come measures was employed to assess June’s progress along with qualita-
tive reflections of her overall improvement. The results were calculated by
changes in point scores and percentages as they are related to clinically sig-
nificant changes in the outcome measures. After June’s discharge, she pro-
vided final ratings regarding her occupational performance and satisfaction,
upper extremity disability, pain catastrophizing thoughts, and pain self-
efficacy. These results were compared with initial visit scores to gauge pro-
gress. The COPM was completed at the initial occupational therapy visit,
the fifth visit, and then again upon discharge. Overall, June’s COPM scores
improved by 3.8 points in performance and 6.6 points in satisfaction, as
rated on her final visit (Table 1) (Davis & Gillard, 2021).
June completed the QuickDASH on the initial visit and after her dis-
charge. She scored 88.64% on the QuickDASH and 100% on the Sports/
Performing Arts Module in terms of Fishing/Gardening on the initial visit,
and she scored 45.45% on the QuickDASH and 37.5% on the Sports/
Performing Arts Module after discharge. She demonstrated a U/E disability
rating improvement of 43.19% on the QuickDASH and 62.5% improve-
ment on the Sports/Performing Arts Module from initial visit to discharge
(Figure 1) (Davis & Gillard, 2021).
June initially scored 36 on the PCS, and then scored 14 after the dis-
charge, rating catastrophizing thoughts less by 22 points (Figure 2).
June’s initial score on the PSEQ-2 was three out of 12, indicating low con-
fidence in her ability to complete some form of work and live a normal life-
style despite her pain. After her discharge, June showed higher self-efficacy
on the PSEQ-2 as demonstrated by a score of 11 out of 12 (Figure 3).
Table 1. Canadian Occupational Performance Measure (COPM).
COPM Performance/Satisfaction Performance/Satisfaction Performance/Satisfaction
Visit 1 Visit 5 Visit 8
Cast a fishing rod 1/1 5/3 6/8
Stir-fry food 2/2 2/1 5/8
Gardening vegetables 1/1 4/4 4/8
Walk 1
=
4mile for leisure 3/2 2/1 8/8
Bathing dogs in the bathtub 1/1 2/1 4/8
Mean value 1.6/1.4 3/2 5.4/8
Changes from Visits 1 to 8 3.8/6.6
Note. Source: Authors.
10 C. DAVIS AND M. GILLARD
While discussing her experience with social engagement and chronic
pain, June mentioned that people “judge you terribly.”She reported how
people would be rude to her and glare at her when she would use a scooter
at the grocery store. She found asking for help from others difficult and
stated, “Asking for help is like swallowing dirt.”June shared about feeling
judged by her family as they stopped inviting her to family social events.
She stated that medical providers generally never took her seriously think-
ing that she was looking for drugs. June felt unheard.
After receiving occupational therapy treatment, June felt more confident and
stated, “I feel like I have woken up”(Davis & Gillard, 2021). She mentions
0
20
40
60
80
100
120
Visit 1 QuickDASH Visit 8 QuickDASH
Visit 1 Sports/Performing Arts Module Visit 8 Sports/Performing Arts Module
Figure 1. QuickDASH.
Note. Source: Authors.
0
5
10
15
20
25
30
35
40
Visit 1 Discharge
Pain Catastrophizing Scale (PCS)
Figure 2. Pain Catastrophizing Scale (PCS).
Note. Source: Authors.
OCCUPATIONAL THERAPY IN MENTAL HEALTH 11
feeling more aware of being unable to perform simple tasks and how this
affected her (Davis & Gillard, 2021). She socializes more, takes the dogs outside
frequently, and she can walk to the mailbox to collect the mail. Her self-efficacy
improvement was noted by the increased confidence to complete meaningful
daily activities.
As June’s confidence improved, so did her ability to communicate her
symptoms and emotions. Her health care team’s trust in her story and their
ability to assist her in vocalizing and understanding her condition
decreased the stigma she felt with past providers and in turn, decreased the
self-stigma she noted to experience. She mentioned that her loved ones
have a deeper understanding and appreciation of her condition beyond
society’s expectations, which increased her confidence with socialization
and when completing tasks outside of the home.
During our final meeting, June appeared different from her initial dis-
position. She was no longer tearful and was smiling. She was well-groomed
and nicely dressed for her appointment, wearing a bright scarf that she had
not previously worn to therapy. She appeared no longer fearful or avoidant
of participating in her own health care decision making, which also indi-
cated improved self-efficacy.
Discussion
Our findings identify PNE as an occupational therapy intervention that
may ameliorate self-stigma and occupational performance. This study
extends the literature discussing the need to reduce the stigma of chronic
pain by educating healthcare professionals on biological, physiological, and
0
2
4
6
8
10
12
Visit 1 Discharge
Pain Self-Efficacy Quesonnaire 2 (PSEQ-2)
Figure 3. Pain Self-Efficacy Questionnaire 2 (PSEQ-2).
Note. Source: Authors.
12 C. DAVIS AND M. GILLARD
psychosocial contributors to the chronic pain experience (De Ruddere &
Craig, 2016; Nielsen, 2012). With new understandings of the chronic pain
experience, healthcare providers can educate their clients, clients’families,
and the community on chronic pain, thereby decreasing associated stigma.
Education and training are common interventions used in occupational
therapy practice along with other interventions to promote participation in
desired and needed occupations. This aligns with the AOTA’s(2021) pos-
ition statement on the Role of Occupational Therapy in Pain Management,
highlighting PNE as an intervention strategy used within an occupational
therapy case example to support the achievement of a client’s occupational
therapy goals.
Education can improve the understanding of all factors that influence a
person’s participation in certain occupations. This education may contrib-
ute to decreasing social stigma and self-stigma by equipping health care
providers, clients, and communities with knowledge on how pain limits
individuals, even when it is undetected and without a physical explanation.
Education can encourage participation because the factors influencing the
pain experience are better understood. Pain is complex, and education spe-
cific to the chronic pain experience can enhance participation in desired
occupations. June reflected on how understanding activity patterns influ-
enced her pain experience and allowed her to increase her occupational
performance and satisfaction. She became confident in completing tasks
and in reporting her needs to others. She knew what to expect and how to
respond to her symptoms based on the education and problem-solving
skills acquired through the therapeutic process.
This case study highlights PNE as an occupational therapy intervention
to decrease pain catastrophizing thoughts and increase self-efficacy, which
in turn may decrease self-stigma and improve occupational performance.
Internalized stigma impacts self-esteem, self-efficacy, and catastrophizing
thoughts about pain (Waugh et al., 2014). Our results support this notion
as June indicated she felt more confidence in her ability to complete tasks
despite her pain and was less worried about how and when her symptoms
may affect her.
June demonstrated significant positive clinical changes in her perform-
ance and satisfaction scores on the COPM and QuickDASH, thus meeting
her goals in occupational therapy. These results indicate the potential of
PNE when combined with other occupational therapy interventions to
decrease self-stigma, increase self-efficacy, and reduce catastrophizing
thoughts. Ryan et al. (2010) found short-term results for individual sessions
of pain biology education, improving self-efficacy in persons with chronic
low back pain more effectively than pain biology education in conjunction
with group exercises for the same target group. When pain is discussed
OCCUPATIONAL THERAPY IN MENTAL HEALTH 13
from a biological, physiological, and psychosocial perspective, it could help
the client, healthcare providers, and the community reconceptualize the
problem and subsequently increase the client’s confidence in their ability to
complete tasks (Moseley, 2004). Moseley’s(2004) discussion on how pain
beliefs could affect motor performance may be correlated with the findings
of this study. June felt prepared for discharge from occupational therapy
when her satisfaction of goal performance improved and exceeded her
actual goal performance. Pain may continue to limit her performance, but
her fear regarding the pain had decreased and she could complete goal
activities more frequently with greater satisfaction.
De Ruddere and Craig (2016) discuss different intervention strategies
to address stigma including educating the individual and the community
and influencing legislative efforts to promote social environments and
prevent occupational marginalization. PNE has the potential to help
decrease self-stigma and may influence people to avoid others’stigma-
tized and incorrect impressions of them. Teaching PNE in the commu-
nity may help people understand their own or others’pain experiences.
PNE provided to middle school students has impacted their pain beliefs
and improved their understanding of pain (Louw et al., 2018). OTs
often provide community-based services and could effectively provide
education on pain to reduce its consequent suffering and stigma.
Addressing social stigma through legislation by advocating for increased
understanding, support, and services provided for persons with FM and
other pain conditions would promote the use of interventions that
reduce stigma and occupational marginalization.
Implications for occupational science and occupational therapy
A larger research study would be beneficial to further understand how
PNE influences self-stigma and occupational performance in chronic pain.
This study provides insights to consider, including how improvement in
occupational satisfaction can outpace one’s performance of the task itself,
which may influence goal achievement, reduce perceived stigma, and help
in the successful self-management of chronic pain conditions such as FM.
Limitations
This is a single-subject case study design; therefore, the authors are unable
to generalize the results of this study in occupational science and occupa-
tional therapy. The study’s objectivity is limited as assessments and inter-
ventions were provided by the same therapist. As June simultaneously
14 C. DAVIS AND M. GILLARD
received services from multiple disciplines during this period, her results
may not be the outcome of a single discipline’s intervention strategies.
Conclusion
To adopt occupational science and occupational therapy efforts to reduce
self-stigma and improve occupational performance of persons with chronic
pain, PNE should be considered as a potential intervention strategy to be
used along with other occupational therapy interventions, as part of a biop-
sychosocial multidisciplinary approach. Through understanding June’s
occupational history and implementing occupational therapy interventions
including PNE, her occupational performance and satisfaction improved on
the COPM. Other improvements included decreased upper extremity dis-
ability ratings on the QuickDASH, decreased pain catastrophizing scores
on the PCS, and higher pain self-efficacy on the PSEQ-2. This retrospective
case study highlights the potential of using a specific education strategy to
decrease factors that may limit occupational performance for clients with
FM, such as self-stigmatization and should be considered further in both
occupational therapy practice and research.
Acknowledgments
The authors would like to thank June for her bravery in allowing us to tell her story, which
will promote understanding and care for all people experiencing similar conditions. We
would also like to thank Editage (www.editage.com) for English language editing. Lastly,
we would like to thank Bridget Scheidler, EdD, OTR, CAPS for her thoughtful insights and
encouragement during the writing process.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Funding
The author(s) reported there is no funding associated with the work featured in this article.
ORCID
Christine Davis http://orcid.org/0000-0002-3132-4978
Data availability statement
The authors confirm that the data supporting the findings of this study are available within
the article.
OCCUPATIONAL THERAPY IN MENTAL HEALTH 15
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