If you’ve got someone you’re working with that just needs to learn how to SLOW DOWN, this website is for you!

Did you know that multitasking is a moral weakness?
Although if you’re a woman, this is slightly less of a problem…

Some great posts here - including this one on the benefits of a Good Night’s Sleep
and this one on the horror of work - I suggest this one for you when you have your next performance review….

And what you really need on a Friday afternoon….A beginner’s guide to slowing down.

Can I suggest you start with a cup of tea and a moment or two reading this blog? It’s a good start! Don’t forget the cup of tea…

There are many people who have completed a pain management programme, know how to do things like breathing, working to quota (pacing), relaxation strategies, distraction and exercise - but when they are asked about returning to work say ‘I can do these things at home, but not at work’.

I have many books on pain management - self-paced learning books, books on cognitive therapy for pain management, academic texts on pain management methods and concepts. What I don’t yet have is a book dedicated to ‘how to apply pain management in the workplace’.

Why should it be different? Well I think for one thing, it’s about the demand characteristics at work alongside the power differential many of the people I work with experience. At home it’s entirely possible to decide ‘I can leave that for a while and come back to it’ - this is often called pacing, although I’m not sure that it really is. While it works at home, where many things can be carried out in ‘chunks’, it’s a very different situation in, for example, a production line, or a plumbing business, or a lawyers office. Deadlines rules in each of these situations - and the individual has little control over what needs to be done, and more importantly, when it can be done.

The power differential at work is really evident for semi-skilled or unskilled workers where they are employed to get a job done, done quickly under the supervision or direction of a skilled worker. For many people this has been their whole working life, and despite years of experience, in the workplace they are required to work as directed. This work is characterised by ‘high demand, low control’ - and it’s common. The demands are to work fast, don’t argue - and many employees feel they have no choices and no power. Their opinion doesn’t count - or they agree that ‘get the job done’ is just the way it’s done at work.

If an individual has only developed pain management strategies that focus on avoiding or controlling pain (eg relaxation and pacing), and the ability to tolerate variations in pain intensity hasn’t fully been developed, it makes sense that it’s going to be difficult to cope with situations where activities need to be maintained despite pain fluctuations.

What are the implications of this? Is there a need for ‘targeted’ pain management to specifically address pain management at work?

I think so - and I think part of why it hasn’t been recognised and developed is that many clinicians are fearful of provoking a flare-up in their clients, perhaps afraid of ‘pushing’ their clients, and/or are themselves unconvinced that it’s possible for people to cope with increases in pain.

Another part of the problem? To date, pain management has been fairly generic - one size fits all. In fact, it’s only been recently that we have become aware that people experiencing chronic pain are not a homogenous ‘chronic pain group’ - they have quite distinct subtypes, even though refining what those subtypes are is yet to be complete!

If we have a complex model of pain, which the biopsychosocial model is, we are likely to have quite complex hypotheses about the factors maintaining disability. This means we need to have tailored approaches to pain management to suit the individual’s needs.

Here are some suggestions for developing pain management for work:

Suggesting to someone, even inadvertently, that they can ‘push through’ the pain won’t work - after all, they have probably been told this before, tried it, had a flare-up, and learned that it’s not pleasant.  Even if they are using a ‘boom and bust’ pattern,  they are usually fully aware that this isn’t the most effective way of managing.

What might work? Identifying what is going through their mind when they start to experience increased pain, and establishing a way to work through that thought. This might mean problem solving, reality testing, using the ‘good’ and ‘not so good’ decisional balance, and perhaps even developing a graded hierarchy of activities so the person can develop confidence that the world won’t end because their pain has increased.

Not allowing the person to experience a flare-up during therapy, not expressing confidence in their ability to cope, not being specific about the skills they have used.  Measuring ’success’ in terms of pain intensity or avoiding a flare-up sends the message to the person that the primary aim of therapy is to avoid pain, and that a flare-up means they have failed.

What might work more effectively?  Working through pain fluctuations using coping strategies - not, as I’ve mentioned above, telling the person to ‘work through’ the pain!  Find out what’s going through the person’s mind, help them see that although it’s an unpleasant experience, it can be tolerated even when it increases from baseline.  Success needs to be measured in terms of two things:

1. Did they use the skills they’ve been developing?
2. Did they manage to get the task they were working on done?

Flare-ups are inevitable: minimsing flare-ups is not necessarily a helpful goal.  Developing confidence in the skills they are learning, learning to use them consistently - now that is a helpful goal.

Developing only passive coping skills (yes, I think relaxation and pacing can, at times, be passive coping!).  These skills are easily recognised and named (therefore often recalled), they can reduce pain intensity and physiological arousal (so reduce distress) - but in many cases, especially the longer forms of relaxation like Jacobsen/progressive relaxation, can’t be carried out readily in a workplace.  Where do you think a builder is going to find to lie down and spend half an hour relaxing?!  More importantly, they can’t readily be used while the person is carrying out activities.  Yes, even pacing means altering the time spent on an activity, which in many workplaces just can’t happen (think of a meatworks production line, a paintbrush assembling factory, a bakery in full swing).

What might help?  Developing other skills such as mindfulness, positive coping statements, body scans and ‘take 5s’, differential relaxation, and so on.  Helping people think about, and practice, applying their skills during activity - even during exercise sessions, while doing the grocery shopping, when driving. This requires specific problem solving to help the person bring the skills to mind, and begin to integrate into their everyday activities.  It doesn’t seem to be enough to simply mention that the skills can be applied in these situations, being specific about when and how to use them seems to be important (as well as monitoring and reinforcing their use before the person is discharged).

Divorcing vocational rehabilitation and pain management from each other will not work. It especially will not work if a person hasn’t developed robust skills that can and are applied consistently.  And it won’t work if vocational rehabilitation is carried out before pain management skills are addressed.

Although they are distinct phases for reducing disability, pain management strategies need to be supported in the challenging context of the workplace. Practitioners who help an individual during the return to work phase need to be familiar with the factors that are prevalent in a workplace - attitudes, beliefs, controls and so on - and be prepared to be respectful of the individual’s concerns then help them address the concerns.  IMHO this is a specialist role, you really need to be someone who has been to workplaces, knows the literature on occupational/workplace culture, and is thoroughly versed in cognitive behavioural pain management (not simply vocational therapy, not simply pain management).

Generalising pain management skills into the ‘real’ world involves a whole raft of skills that I am not sure have been thoroughly researched or analysed - yet.  Certain professions have an advantage in this, and yes, I think occupational therapists are well-suited to the task - IF and only IF they have developed skills in cognitive behavioural pain management.  A challenge to consider huh?

Hah! now I’ve never really understood fMRI except as a vague generalisation that it ’shows blood flow which correlates to neuronal activity’.

This post found on MindHacks (see my ‘blogroll’ for the link!) leads to several helpful readings about what fMRI actually measures, how it does so, and more importantly, says ‘our understanding of what brain scanning data tells us evolves over time. A study conducted ten years ago might mean something different now.’

People who are sceptical of science will possibly sieze on this as confirmation that ‘you can’t trust science, it could be wrong’ - but for me, it shows how open science is to revision in the light of new information.

Anyway, that was an aside: head on over to the post, and check out some of the supporting readings, I think it’s helpful, albeit needing a little time to digest!

For many years I’ve worked in pain management and tried to help people return to work as the completion of their rehabilitation. Why? Well, apart from it being a great thing from an insurer or funder’s point of view, it’s actually what people want.

Having been through my own return to work rehabilitation after my concussion, I can personally describe some of the effects of return to work efforts - and the fears and concerns I had (and still have to some extent). However, as you know I don’t like to rely on my own personal opinion, so I thought today I’d describe the comments of participants in the pain management programme I work in.

The question participants are asked is ‘What does work mean to you?’

And their responses?
The first group of comments is that ‘work is necessary for money’, and the second ‘to get case managers off my back’ - and then some more thoughtful responses.

Here people say very clearly that work is about meaning and purpose in life, the activity that organises the day, the topic of conversation, the social interaction, the belongingness to a community, contributing to society, identity and self worth and competence.

For some interesting snapshots of what workers say (at least a group of them in the US), listen to this series of podcasts on ‘Meaning of work’. And for a slightly different take on the meaning and value of work, this community arts project by Lara Lepionka provides a wonderful doorway into the meaning of work to ‘ordinary people’.

When they are not working, participants agree that it may be fine initially, but rapidly becomes a much less positive experience. Some health researchers state that stopping work hastens ill health and death. At the very least, participants in the pain management programme agree that they don’t want to remain off work - but they lack confidence to actually return to employment.

When I read assessments of workplaces carried out by various therapists, something is missing. Each assessment covers the physical activities, the equipment, the tasks, the physical environment - but given the amount of time we typically spend in a workplace, I see very little description of some of the fundamental aspects of the culture of a workplace. More importantly, the relationships between people in the workplace are rarely mentioned.

If we return to social learning theory (remember Bandura?), and our behavioural fundamentals, we can see that responses from people within an environment are a particularly potent influence on both behaviour and belief. It’s surprising then, that assessments of the workplace, particularly when an individual is having trouble returning to work, don’t even mention attitudes, beliefs, or behaviours of the other people in the workplace. Workers spend roughly 8 or more hours in a work environment, have strong opinions about their workplace (whether they like it or lump it!), and among some of the so-called ‘black flags’ and ‘blue flags’ (see this 2002 BMJ article), the individual’s perceptions of the workplace and the organisational and task demands of the workplace feature as risk factors for people to fail to return to work.

Even in comprehensive pain assessments, although mention is made of work and past working history, mention is rarely made of the person’s belief about whether they will return to work (which is probably one of the most predictive questions for RTW I know of!), and even less of the employer-employee relationship or the social-cultural and organisational factors in the workplace.

There are multiple reasons for people having difficulty returning to work. One of the most commonly cited reasons, given by case managers, employers, and treating clinicians is ‘lack of motivation’.
It’s time to deconstruct ‘motivation’ and explore what motivation consists of - if we follow Prochaska and DiClemente’s Transtheoretical Model of Change, it’s made up of two major components: importance and confidence.

People are ambivalent about moving forward because the ‘good things’ about change are balanced by the ‘not so good things’. In returning to work, the ‘good things’ are all those reasons given by the participants in the pain management programme. The ‘not so good things’ are much more varied, and require individual assessment and problem-solving.
Most of the ‘good things’ about returning to work are things that make up the ‘importance’ dimension - things that people value.
Many of the ‘not so good things’ are about confidence to achieve those valued goals.

Motivation is therefore much less about lack of ‘importance’ of returning to work - in fact, for some people I would think that it’s precisely because work is so important that they are stuck. Why risk failure for something that is so important? Motivation in the case of people returning to work involves confidence that the individual can achieve within a workplace to the desired and required standard of performance.

What is all this commentary leading to?

1. Pain assessments for people experiencing work disability simply must assess the social and cultural aspects of the workplace - both past workplace and present (especially if the person still has a job)
2. Workplace assessments can’t just consider the physical, but also organisational, interpersonal and ‘cultural’
3. When someone is having trouble returning to work at least one question should be asked: ‘do you think you will return to work?’
4. When someone is having trouble returning to work, ‘motivation’ needs to be deconstructed: it’s more complex than simply the presence of secondary gain, laziness, lack of desire.  The importance and confidence an individual has for returning to work must be assessed, and the process of (often) building confidence initiated.

Pain may well be the cited reason for someone not being able to return to work - is it the real reason?  Disability from pain is a very complicated beast, pain intensity is not, by itself, the major factor.  When we start to look at it in more detail (which we will do tomorrow!), it could be any number of things.  If we fail to clearly identify the specific factors in any one individual, we run the risk of prolonged absence from work which is not desireable for anyone.  At the same time, what we know from motivational interviewing is the more we push against resistance the more defended that position will be.  Simply implying to someone that they are ‘not motivated’ will not achieve the desired goal if it is actually about confidence to manage the barriers around working.

Have a great day - sorry there are no specific references today, but I will make up for that very soon indeed!

In the meantime, you can’t really go past Chris Main and Chris Spanswick’s book ‘Chronic Pain: An Interdisciplinary Approach’ for a good description of the process of disability, incorporating the ‘blue and black’ flags.

I posted yesterday about how little social and cultural factors seem to be included in assessing and managing pain, and I had hoped to find some papers to discuss today. Events conspired and I have failed in that endeavour, so this post is, unusually for me, almost entirely my opinion.

So, sticking my neck out, why do I think the sociocultural context needs to be included when someone presents with their pain problem?

Well, the first thing that springs to mind is how has that person has found their way to a treatment facility - how did they get referred and by whom? To present for treatment means that at some point, this person has decided the pain they are experiencing is undesirable, and something needs to be done about it (whether that ’something’ is diagnosis, elimination or confirmation of its impact). This decision to seek help seems to be based largely on whether it’s ‘normal’ or ‘expected’ in the culture in which the person lives.

Let me give you an example: and yes, it’s perhaps a little outrageous, and yes, it does relate to acute pain!
In one group in New Zealand society, body piercing and suspension is one way to generate a ‘natural high’. The individual and his or her supporters (usually members of the same social group) congregate and encourage each other through the process of suspending the body from large hooks inserted through the skin of the back. As the process continues, some of the participants begin to swing their bodies from the hooks, and I’ve watched one participant swing and run across a stage to gain more momentum. Although the physical trauma is clear and pain is experienced as the hooks are initially inserted, over the 10 - 20 minutes of the process, these individuals start to feel euphoric and describe the feeling as ‘bringing me closer to a spiritual plane’, ‘overcoming my physical self’, ‘getting in touch with the inner self’.

The practice of body piercing is ancient, and an accepted part of many cultures including Sri Lanka where it forms a part of a ritual to the Hindu god Murugan, and the Phillipines where ritual re-enactments of the crucifixion, complete with nails piercing the hands are performed on Good Friday. Tattooing is also an accepted part of many cultures including New Zealand Maori and the Pacific Islands.

For many of us, the thought of submitting to painful procedures as a recreational activity is just not something we would ever do. However, we may participate in weekend sports - netball, rugby, skiing, running, weight-training…and sustain pain with the ’support’ of our friends!

So it’s not surprising that if our willingness to experience acute pain can be influenced by social and cultural factors, treatment seeking for persistent pain can also be influenced.

Two common pain problems come to mind: the headache and the backache. Headaches are usually managed with simple analgesia and a quiet night or a walk. Backaches - well for many of us (around half of those that have an episode of back pain in a year (Walker, Muller & Grant, 2004) we will seek health care from a GP or chiropracter or similar. If we don’t initially attend, our families and friends or employers will suggest we do if our function is affected. Who we see will be influenced by our culture - in New Zealand, it’ll be a GP or physiotherapist or chiropracter; in rural China, it will more likely be a practitioner of traditional chinese medicine, or an acupuncturist.

The impact of even our acute pain on our lives will depend on our social context - our work, whether we live alone, the responsibilities for household tasks or caring for family members. And most especially, our pain behaviours will be influenced by others around us - our nearest and dearest strongly shape the kinds of things we do when we are sore (e.g. Smith, Keefe, Caldwell, Romano & Baucom, 2004).

And these are the things that we may well miss assessing if we don’t meet the person’s family (how many people attend a pain assessment alone, without any family present?), or talk to their colleagues. What’s more, we don’t typically include these people in management either - despite our knowledge that people changing behaviour really need to have the support of those who see them every day, especially in the period immediately after a pain management programme. In New Zealand anyway, ACC claimants receiving compensation for an accident rarely have encouragement or funding to enable their family members to also be included in intervention - even when roles have changed significantly, or the relationship is under strain. The ‘claimant’ is the person with the problem - even when we know that people live within a family, community, social, sporting, church system.

Tomorrow I hope to post on some of the factors to assess when considering the sociocultural and contextual factors in a person’s pain experience. If you’ve enjoyed this post, and want to read more - don’t forget you can subscribe using the RSS feed button at the top of the page, or you can simply bookmark the blog. And I love comments and respond - even if you don’t like what I have to say!

Smith, S. J. A., Keefe, F. J., Caldwell, D. S., Romano, J., & Baucom, D. (2004). Gender differences in patient-spouse interactions: A sequential analysis of behavioral interactions in patients having osteoarthritic knee pain. Pain, 112(1-2), 183-187.

Walker, B. F., Muller, R., & Grant, W. D. (2004). Low back pain in Australian adults. health provider utilization and care seeking. Journal of Manipulative & Physiological Therapeutics, 27(5), 327-335.

Using cognitive behavioral therapies in pain management isn’t really rocket science, it’s simply being aware of the principles of learning from both a cognitive (thinking) point of view and a behavioural point of view. It is, however, complex - by that I mean, there are many threads to systematically follow and actively manage.

There does need to be a fairly large emphasis on assessing or understanding (or formulating, if you prefer psychological language) the factors that are working together to influence the person’s presentation. A formulation is simply a set of premises or hypotheses that, if they are tested and found to hold true, help to explain why this person is presenting the way they are, and to predict how they might respond in certain situations.

In chronic pain management, this means incorporating biophysical or biomedical elements, along with psychological and social elements. The complex blending of all these factors is what gives each individual a unique presentation and a unique set of concerns. And this is why it’s important never to think there is a ’standard’ or routine way to help people with chronic pain develop ways to cope and move forward. ‘Cookie cutter’ or ‘recipe’ methods simply won’t work as effectively as an individualised approach.

My main concern currently is that the biomedical/biophysical and psychological aspects of assessment are fairly well covered in many settings - the aspect that is least well assessed and addressed is the social. ‘Social’ covers an area of influence that begins with interactions between the individual and his or her family, through to the influence of mass media and systems of governance and policy within a society. I think in New Zealand anyway, the psychological assessments are becoming over-emphasised, and the lack of emphasis on roles, function, interactions

Today let’s look at the words of people experiencing chronic pain - a great reading is Mandy Corbett, Nadine E. Foster, Bie Nio Ong’s paper ‘Living with low back pain—Stories of hope and despair’.

It incorporates the narratives of six people experiencing chronic pain, and themes that emerge include the fluctuating emotions of hope and despair. A number of linked themes emerged which influenced the extent to which people oscillate between hope and despair, the most salient of which were ‘uncertainty’, ‘impact on self’, ‘social context of living with pain’, and ‘worry and fear of the future’. It is clear from the narrative accounts that it is not only just physical pain that the back pain sufferer must endure, but also that the psychosocial implications pose an added and often complicated challenge.

‘They [others with back pain] go through what
I’ve been through. They’ve got to come through
it all: the stress, the anger, er…the feeling of
..er.. uselessness, and it can take a toll on a
marriage and a family so bad, to the point that,
that person may not have a family in 18 months,
four years’

‘You know, I can’t have one
day a week off. I’ve got to do full-time and I’m
finding it very hard and I’m frightened that I’m
going to do it because I have to, but then I end up
getting worse and I just can’t cope. What do I
do? Because that worries me. I can’t go off sick. I
can’t afford to go on half pay. So .. so that’s a
real dilemma.’

‘He positions himself as a social persona
who contributes both to his family and to the
community, and re-affirming himself in this way
forms the foundation for a generalised hope where
he can have faith in the future’

Can we spend a while listening to the social context of the people we work with? Considering both the impact and the influence of the wider social factors that abound when an individual experiences their personal pain.

More tomorrow on the social context of pain.

Corbett, M., et al. Living with low back pain—Stories of hope and despair. Social Science & Medicine (2007), doi:10.1016/j.socscimed.2007.06.008

This is the last post in this mini-series on why I use science when deciding what interventions to use as a therapist.  As I did yesterday and the day before, I refer to William Palya’s book on research methods - it’s easy to read, available on the internet for free, and although it gives only one view of scientific method, it’s a good start.

After having discussed the first onus - which is to be ethical, and the second, which is to be pragmatic, the third is to use a method to help achieve one or both aims. There are two basic things you need to do:
(1) Demand truth and
(2) Have good understanding

So, what is truth?
Well this can get into murky waters - especially if you listen to the philosophers! But for practical purposes, we can assume that ‘truth is an accurate description of something that is real’. It’s process of building up evidence from many sources, at different times, in different places that describe the same thing, using the least number of assumptions or appeals to special factors that can’t be tested, and describing the majority of the thing under examination. We can use the word ‘phenomenon’ instead of ‘thing’, or ‘event’ or ‘factor’.

Empiricism is one way that is used to determine ‘truth’. Something that is empirical is observed - through technology, to be sure, but can in some way, correspond with something that exists in the real world. As Palya puts it ‘If we wish to claim that something we cannot experience is real then the burden is on us to prove it to a skeptical audience; that is only fair.’

The evidence needs to be reliable - that is, if you look at it more than once, it should be the same. It should also be the same if anyone looks at it.

There should be more than one source of evidence for the ‘thing’. Palya’s example may help - ‘The more evidence from the wider a variety of sources, the more believable. If the police find a finger print the same as yours at a murder scene, maybe it means you are guilty, maybe it doesn’t. However, if the police also find your wallet there, and the murder weapon in your house, and the tire tracks of your car at the murder scene, and the victim’s jewelry at your house, and your teeth marks on the victim’s throat, and a VCR tape of the murder with you in the starring role - well, then you’re in trouble.‘

You can’t be the only person to say it’s so - and the others that agree with you also need to hold to the same ideas about what is ‘true’ and ‘real’. ‘If several observers who abide by the “rules” of science all agree concerning an event then it is probably true. It is reliable, it is objective. If only one person observes something and others do not observe the same thing then it is subjective.’

The phenomenon needs to be carefully defined so we all agree on what it is and that it describes the essence of the phenomenon. ‘The concept of a horse is false if it includes the saddle or fails to include four legs; it is false if it includes speaking English or fails to include galloping.’
The implications of this aspect of ‘truth’ is that the words we use to describe need to include the critical or essential elements, while excluding those that are not essential. A good definition is unambiguous with respect to what is included and what is not.

The definition you provide must actually have an impact on something that can be measured - because if you can’t confirm that it affects something, it might as well not exist.
‘Things cannot be said to exist outside the impact they have on sensation (resulting measures) or the impact on other things (functional definition). If your idea of the correct concept of a thing exceeds its operational/functional definition, the burden of proof or burden of communication is on you to prove, explain, and communicate the difference.’

I leave the best summary again to Palya: ‘we start with the notion of empirical, reliable evidence with multiple converging support which is operationally/functionally defined and has consensual validation and ask what is beyond. If someone wants to offer something else as a “truth” it must be proven. Truth does not mean anything anybody wants it to mean. Anyone wanting to extend the meaning of truth to something beyond what science has already substantiated must explain to us what they are talking about.’

Some people say that because various ideas that were once strongly supported by scientists have been rebutted in recent years that there is no such thing as ‘truth’ and science is nothing more than a set of opinions that change all the time. (eg disc prolapses on MRI were once thought to indicate the source of back pain and therefore needed surgery, now they are thought to be incidental and possibly a ‘normal’ variant in many cases)

Some things do change over time - not because the ‘truth’ part changes, but because more information comes to hand that explains more, or explains more with fewer special assumptions, or has more robust support than the previous ‘truth’. This is, in part, why we describe ‘truths’ as theories - theories can be and should be continually tested and as a result, refined. If a theory cannot be tested - then it’s really a model and needs to be evaluated in terms of how useful it is. If it doesn’t help with making decisions that can be tested, then it’s not useful at all.

Whew!! That’s a lot of theory and philosophy of science!
I think though, that it’s really important that we, as therapists, work out why we use the interventions we do, and that we can point to a method that means we feel we can rely on the interventions - and that we really do understand what we mean by evidence and science. Otherwise we are only reciting by rote, or working by habit and convention rather than seeking to understand.

What’s understanding?
It means you can describe, predict, know how to influence, synthesise and explain what you are actually doing.

This is from Palya’s chapter - summarises it quite neatly I think!

Have a great weekend - it’s Friday here, and I’m about to look for a Friday Funny. Be back soon!

Yesterday I blogged about why I am so keen to use science to help me work ethically with clients. I talked about the basic onuses that we accept when we decide to become therapists, and showed how these are no more than what I would hope to receive if I saw a therapist or plumber or accountant.

I refer much to William Palya’s Research Methods pages not because it’s the last word on scientific methodology, but because it’s a starting point, and he writes in a very readable way.

Today I want to move on to being pragmatic.
This is the second onus that we usually accept - these are the skills that we need to be secure and successful in our clinical practice, and lead to the reason for using the scientific method as the way to meet both obligations. Once again, I’m quoting mainly from Palya’s work, but paraphrasing and applying it to health practice across all disciplines.

To be pragmatic, you need to:
a. Be a Good Consumer / Separate Illusion from Reality
All theories claim to be correct and all therapies claim to be right. If you are to become a good consumer or practitioner of health care knowledge you must be able to separate truth from fiction even when appearances are deceiving.
b. Ability to Implement Complex Information
You must be able to understand the advanced and sophisticated knowledge of health care in order to properly function as a therapist. Knowledge of people, health and therapy has exploded in the past 20 years and to sift through it all requires skill.
c. Solve Unique Problems by Applying Concepts
Technicians can cope with problems once they are trained to step through that particular solution. A professional on the other hand can solve problems which have never before occurred because they are trained how to identify underlying patterns and apply principles to novel situations. In general, a professional must have the analytical skills necessary to unravel complex behaviors into understood functional relationships, and the competency to design procedures which will clarify causal factors or which will alter behavior.
d. Make Consistent Progress
If you are to succeed at what you are doing you must be right more often than you are wrong. If you are to make consistent progress then you must know when things are getting better and when they are getting worse. With accurate feedback, errors can be eliminated and correct solutions obtained. ‘Common sense’ moves you back and forth in no consistent direction because there are so many competing and opposing ‘common beliefs’. (e.g., it’s never too late, you can’t teach an old dog new tricks / he who hesitates is lost, look before you leap).
e. Prove Effectiveness
You will be required to demonstrate the efficacy of what you do because when the people supplying your income become good consumers, they will demand it of you. This will include: Funding agencies, the Courts, to ensure ongoing employment.

To be both pragmatic and ethical, you’ll need to use a scientific perspective as the only perspective. Why?
Because you need good evidence that things are true before you believe in them. Think of the coin toss result hidden in my pocket - if I gain from your choice, why would you trust my word? You’d really want someone else (if not yourself) to check it out.

Finding ‘truth’ or what approximates it given the current state of knowledge is not as simple as it sounds.
1. Unfortunately, truth is not necessarily obvious, what you like, nor the easiest.
2. Neither is common sense an acceptable arbiter of reality. Common sense can be as dangerous as helpful. Common sense is often true only in the sense that ‘home truths’ predict everything, for example “opportunity knocks once”, and “it’s never too late.” One or the other is certainly true on any one occasion. The need is to know in advance not after the fact when it is too late.
3. Just because your mother, teacher, or best friend believes something does not make it true either. That your friends support your view is no help. Everyone, including a psychopathic murderer, has a mother, a best friend and a dog that believes in them.
4. The fact that something is popularly known is also no reason to believe in it. Everything that is now known to be wrong was once thought to be true by people in the street.
5. Knowing or feeling that you’re right is of no help. Even though most people do believe that they can be wrong, few people ever believe that they are wrong “this” time. Most people (including you) can be talked into believing a nonsensical theory especially if it’s full of jargon, and the person talking to you has power, seems charismatic and you’ve paid for their advice.

You need to accept that any special “inner ability to understand people and recognize the truth” could be the problem rather than the solution. The only way to move past guesswork or habit is to determine what in the past has been shown to produce truth as opposed to procedures which only produced strong emotional commitment but make little lasting change.

What’s truth? Now let’s leave the Great Debate to philosophers, simply put there must be rules to screen-out ‘knowing-that-you’re-right’, opinion, bias and conjecture from truth. Truth is an as-accurate-as-possible description of something that is real, or works, or explains the most with the fewest ’special’ assumptions. If three people tell you three different combinations to a safe, the one that works is the truth. It means that the information has passed a reality test.

There are some tried and true ways to determine the truth of a claim: more on this next week.
In the meantime, let me know if this is interesting, challenging or just off the wall!  I know I never learned this when I trained as an occupational therapist years ago - I wish I had, because it has confirmed to me that in order to be honest and authentic in what I offer to people, I need to learn how to check the veracity of what I do.

Every month like clockwork ‘How to cope with Pain’ Blog has a carnival roundup of the best in pain management posts in the internet. If you haven’t visited before, head on over there today - loads of things to read, and links to places I’ll bet you haven’t been before.