The Vocational Continuum: How to Make Sense of Vocational Outcomes After Group Cognitive Behavioural Therapy for Chronic Pain Sufferers


Introduction Vocational outcomes following group CBT programmes for patients with chronic pain are scarcely reported within the literature, despite their importance as measures of function. This study reports vocational, physical and psychological outcomes following a group CBT programme for patients suffering chronic pain. The study aimed to examine the vocational situation of chronic pain patients who completed a group CBT programme, using a scale known as the vocational continuum. The scale was developed to measure changes in RTW intention and work status, in an effort to reconceptualise vocational outcomes for this population with respect to the RTW process. Methods A group of patients referred to a hospital pain clinic that went on to complete a group CBT programme were retrospectively surveyed about their vocational status at various time points. Physical outcomes measured included the 12-min walk test, 2-min sit to stand test, 2-min stair climb test and timed 20-m walk test. Psychological outcomes measured included pain intensity, self-efficacy, psychological distress (depression, anxiety and stress), catastrophising and disability. Responses to vocational items including work status, hours of work, intention to RTW and barriers to RTW were incorporated into the vocational continuum. Results Two hundred and nine (58%) of the 360 patients who completed the group CBT programme between 1998 and 2005 completed the vocational survey. Ninety percent of participants reported that their chronic pain was a barrier to RTW or increasing hours of work pre-CBT. According to the vocational continuum, fifty per cent of the study population advanced toward working full-time (χ2(2, N = 163) = 28.87, < 0.01) and this result was associated with a significant reduction in pain as a reported barrier to RTW or increasing participation in work post-CBT. Significant improvements were seen across all physical and psychological measures for study participants at 1, 6 and 12 month intervals post-CBT. Conclusions The study demonstrates improvements across physical and psychological measures post-CBT, indicating that participants benefited from reduced levels of pain-related distress and disability. Although retrospective, the study also suggests improvements were made across vocational outcomes. By doing so, the study adds to scant literature reporting on vocational outcomes of group CBT programmes for patients with chronic pain and offers a new scale for measuring and interpreting vocational outcomes for this population.

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The authors would like to thank the patients and Dr. Andrew Muir of the Barbara Walker Centre for Pain Management at St Vincent’s Hospital, Melbourne for supporting this project. We also wish to offer our thanks to the anonymous reviewer for their helpful suggestions.

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Correspondence to Darren C. White.


Appendix A

Eligibility for START

Patients are offered the START Programme after completing a comprehensive multidisciplinary assessment process. Providing they meet none of the specified exclusion criteria (see below) and at least two of the inclusion criteria (see below) the patient is offered a position in the programme.

Exclusion criteria:

  1. 1.

    Unmotivated or unwilling to participate in the Programme

  2. 2.

    Unable to understand English and/or relevant concepts

  3. 3.

    Active major psychiatric illness (e.g. psychosis, clear suicide risk)

  4. 4.

    Eligible/require further medical/surgical treatment or investigations

  5. 5.

    Pain less than 3-months duration

  6. 6.

    Primary substance dependence

  7. 7.

    Use of injectable medication aimed at managing pain

  8. 8.

    Unable to perform programme activities due to specific illness (e.g. cardiac conditions)

Inclusion criteria:

  1. 1.

    Widespread reduction in normal activities due to pain

  2. 2.

    Habitual overactivity leading to increased pain

  3. 3.

    Excessive or inappropriate medication intake

  4. 4.

    High levels of pain behaviour (e.g. excessive pain focus)

  5. 5.

    Work reduced or ceased due to pain

  6. 6.

    Distressed mood (e.g. anxiety, depression) secondary to pain-related problems

  7. 7.

    Based upon staff assessment, the patient is highly likely to benefit from START

Appendix B

  • Return to work (RTW): Refers to an individual resuming work (paid or unpaid) after a period of absence.

  • RTW intention (RTWI): Refers to an individual’s intention to RTW.

  • RTWI o : Refers to an individual who has no intention to RTW.

  • RTWI i : Refers to an individual who intends on RTW but is not seeking work (i.e. behaviourally inactive).

  • RTWI a : Refers to an individual who intends on RTW and is seeking work (i.e. behaviourally active)

  • Work Status (W): Refers to an individual’s labour force status (i.e. where an individual is regarded as either not working or working in a paid and/or unpaid capacity).

  • Hours working (HW): Refers to the number of hours per week an individual spends working.

  • Vocational Continuum (VC): A scale comprising RTWI and work status.

  • Retired: A term study participants used to define their vocational situation.

  • Barriers to RTW: Impediments to an individual’s progress in RTW.

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White, D.C., Beecham, R. & Kirkwood, K. The Vocational Continuum: How to Make Sense of Vocational Outcomes After Group Cognitive Behavioural Therapy for Chronic Pain Sufferers. J Occup Rehabil 18, 307–317 (2008) doi:10.1007/s10926-008-9141-4

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  • Vocational
  • Outcomes
  • Cognitive behavioural therapy
  • Chronic
  • Pain