San Diego Pain Summit – only a few days to go, but you’re not too late!


Live Stream package details: Watch the conference on Feb. 23-24 in real time. Note that the conference occurs in Pacific Standard Time. Participate in Q&A and prize drawings.

Package includes 1 year membership to Pain Summit Online, beg. March 1, 2019. Membership includes access to all presentations from 2015 to present. The 2019 presentations will be uploaded sometime in the first few weeks of March.

Live Stream video contains a lag, so you can rewind hours later to watch something you missed.

Approved by the California Physical Therapy Association for 1.15 CEUs or 11.5 hours.

Link to register: https://sandiegopainscience.com/registration-2019/live-stream

Registration closes at 11pm PST on Feb. 22

Discount code for 25% off at checkout: T9SQZGM

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Reconciling uncertainty and the drive to diagnose


Recently it was suggested to me that even though I’m an occupational therapist, I might “diagnose”. Not so much diagnose disease, but “determine if a patient is depressed, anxious, catastrophising, fear avoidant etc?” The author goes on to say “isn’t that diagnosis too?” The comment was made in the context of a lengthy Twitter discussion about so-called “non-specific” low back pain. Over the course of I think about five weeks now, a large number of highly educated, erudite and passionate clinicians have argued the toss about whether it’s possible to identify the “cause” of nonspecific low back pain. On the odd occasion I’ve put my oar in to mention psychosocial aspects and that people seek help for many reasons, one of which may be pain intensity, but mostly people ask for help because either the pain is interfering with being able to do things, or because the person interprets their pain as an indication, perhaps, of something nasty.

I mention this context, because over the many tweets, I was struck by the degree of certainty demanded by various commentators on both sides of the discussion. “Where’s the gold standard?”; “What’s the evidence”; “Yes”; “No” – and in many respects, diagnosis is a practice based on degrees of certainty. You either have a disease – or you don’t. You have the signs and symptoms – or you don’t. Unless, of course, it’s the creeping edge of “pre-diagnosis” like my “pre-diabetes”.

In October I wrote about clinical enquiry, which is described by Engebretsen and colleagues (2015) as a complicated process (sure is!) of 4 overlapping, intertwined phases: (a) data collection – of self reported sensations, observations, otherwise known as “something is wrong and needs explaining”; (b) data interpreting “what might this mean?” by synthesising the data and working to recognise possible answers, or understanding; (c) weighing up alternative interpretations by judging; and (d) deciding what to do next, “what is the right thing to do”, or deliberation.

For, irrespective of our certainty about the precision of any particular test or ultimately a diagnosis, all of our work involves two people who must collaborate to follow the process outlined by Engebretsen and colleagues. That is, the person seeking help notices “something is wrong and needs explaining”, he or she communicates selected information to a knowledgeable person (a clinician) and that clinician will typically seek more information, and assemble this in some way (synthesise). In my case I like to do this assemblage in collaboration with the person so we can weigh up or judge various interpretations of that data. I bring some knowledge from my training and ongoing learning, while the person brings his or her intimate knowledge of what it is like to be experiencing that “something is wrong.” There are times when we are both in the dark and we need to collect some more information: for while the person knows what it is like to be in this predicament, there are likely factors not yet incorporated (or noticed) into the picture. For example, guided discovery or Socratic questioning usually involves exploring something the person is aware of but hadn’t considered relevant, or hadn’t joined the dots. I don’t think it takes rocket science to see just how messy and complex this communication and information synthesising process can be – it only takes a person to fail to provide a piece of information (because they don’t think it’s relevant) for the analysis to go awry.

I like the depiction of the diagnostic process described in Britannica.com because throughout the process, the diagnosis is held lightly. It’s provisional. The process of diagnosing is seen as a series of hypotheses that are tested as the treatment progresses. In other words, despite beginning treatment, clinicians are constantly testing the adequacy and accuracy of their clinical reasoning, being ready to change tack should the outcome not quite stack up.

As a clinician and commentator who focuses on the relationship between people with pain and the clinicians they see, it strikes me yet again that the process of diagnosis is often one of relative uncertainty. While it’s pretty easy to determine that a bone is fractured, when pain is the presenting problem and because imaging cannot show pain (and when there are few other clear-cut signs), the clinical reasoning process is far more uncertain.

As I would expect, I’m not the first person to ponder the certainty and uncertainty dilemma in diagnosis. Some of my favourite authors, Kersti Malterud and colleagues (and especially Anne-Marie Jutel!) wrote an editorial for the British Journal of General Practice in which they argue that uncertainty, far from being “the new Achilles heel of general practice (Jones, 2016), instead is absolutely typical of the complexity involved in general practice diagnostic work. They go on to say “The nature of clinical knowledge rests on interpretation and judgment of bits and pieces of information which will always be partial and situated. In this commentary, we argue that the quality of diagnosis in general practice is compromised by believing that uncertainty can, and should, be eliminated.” (p. 244).

In their editorial, Malterud and colleagues point out that the person’s story is essential for diagnosis – and that people have all sorts of reasons for not disclosing everything a clinician might want to know. One of those reasons may well be the clinician’s capability for demonstrating willingness to listen. They also argue that models of disease are social and therefore dynamic (ie what we consider to be disease shifts – pre-diabetes is a good example). People who don’t fit the received model of “what a symptom should be” may not be heard (think of women with heart disease may not present in the same way as men), while those with “medically unexplained” problems just do not fit a disease model.

They make the point that clinicians need to recognise that clinical testing “does not eliminate uncertainty, rather the opposite as it introduces false positive and negative results.” For my money, diagnostic testing should only be used if, as a result of that diagnosis, clinical management will change – and just to add another dollop of my opinion, I’d rather avoid testing if not only does clinical management not change, but outcomes are no different!

I think the call for certainty emerges from what Malterud and co describe as “The rationalist tradition” which “seeks to provide a world of apparent security where certainty is readily achievable.” The problems of both low back pain and many types of mental illness demonstrate very clearly that knowledge allowing us to be certain only covers a tiny amount of the territory of ill health. There is more unknown and uncertain than certain.

I’ll end with this quote from Malterud and co’s paper “Clinical practice must therefore develop and rely on epistemological rules beyond prediction and accuracy, acknowledging uncertainty as an important feature of knowledge and decision making. Nowotny (2016) suggests the notion ‘cunning of uncertainty’ as a strategy where we get to know uncertainty and acquire the skills to live with it.” In occupational therapy practice, uncertainty is always present in our problem-solving process – and consequently I don’t “diagnose”. I never know the effect of a tendency to “think the worst” or “worry” or “avoid because I’m scared” – the constructs it was suggested that I “diagnose”. Firstly because while I might recognise a pattern or tendency – I don’t know when, where, how or why the person may do that thing. And context, purpose, motivation and response all matter when it comes to people and what they do. And secondly, diagnosing suggests that we have a clear and specific approach to treat – and in most of my clinical work, certainty around outcome is definitely not a thing. We never really know if our suggestions are “right” because most of the impact of what we suggest is on the person within his or her own life. In my practice the outcomes ultimately determine how well I’ve worked with someone. Perhaps NSLBP is another of these human predicaments where being certain is less advantageous than embracing uncertainty and an unfolding narrative in someone’s life.



Engebretsen, E., Vøllestad, N. K., Wahl, A. K., Robinson, H. S., & Heggen, K. (2015). Unpacking the process of interpretation in evidence‐based decision making. Journal of Evaluation in Clinical Practice, 21(3), 529-531.

Malterud, K., Guassora, A. D., Reventlow, S., & Jutel, A. (2017). Embracing uncertainty to advance diagnosis in general practice. British Journal of General Practice, 67(659), 244-245. doi:10.3399/bjgp17X690941

Nowotny H. The cunning of uncertainty. Cambridge: Polity Press, 2016

Why do clinicians fear telling people their pain may persist?


There is a big void in our understanding of interactions between clinicians and people who live with persistent pain, and that vacuum is about how people learn that their pain is not going anywhere soon. Recently I searched for qualitative research examining the conversations between clinicians and patients at the moment of diagnosis: that moment when a clinician says “I’m sorry, but you’ve tried all there is to try, and it looks like your pain might not respond”. Or it might be “We’ve found out what your problem is, but we know that right now, there aren’t any very effective treatments”.

Oddly enough – or perhaps not – this is incredibly difficult to find. I wasn’t able to locate any specific studies (though if someone else has found some I’d be very happy to get a list!). The closest I found was a synthesis of qualitative studies by Toye, Seers and Barker (2017) looking at the experiences of healthcare professionals while treating people with persistent pain. In it, the authors identify six themes that seemed apparent after synthesising the included studies:

  • Skepticism in medicine where a person is ill – but diagnosis is difficult. The authors point to the strong culture within medicine in which subjectivity is valued less (they say “shunned”) than objectivity. But of course, pain is always subjective.
  • Clinicians have to “do the work” of reconciling the person they see in front of them and the absence of objective clinical findings – this is difficult when a biomedical model is preferred over a biopsychosocial model. (I could add here that unless that biopsychosocial model is truly integrated as a whole, it could turn into a dichotomous not “bio” then “psychosocial” but that’s another discussion)…
  • Clinicians also have to work in a space where either their clinical knowledge is not relevant, or it’s actively unhelpful, meanwhile trying to help a person who wants and needs certainty and support.
  • Clinicians also have a dual duty: responding to the person who is distressed while also remaining aware that some of what the person wants may not be helpful or good – with some of the concerns being also about the healthcare system, and using investigations that are unnecessary and wasteful.
  • As a result of these multiple demands on clinical balance, clinicians may bear a personal cost in terms of emotional energy, empathy and perhaps as a result find it difficult to want to engage with people for whom they feel the “work” will be hard and unrewarding.
  • Ultimately, clinicians working in this field develop a “craft of pain management” which they believe defies algorithms and categorisations, and instead is an ongoing interplay of call and response.

I can completely understand these challenges. If clinicians “measures of success” are resolution or a problem, or at least effective management of a problem, the difficulty in most instances of persistent neuropathic or nociplastic pain is the limited number of medications, and their relatively poor effectiveness. And other approaches (exercise, coping strategies etc) are equally limited. So – we might need to establish a different measure of success, and that’s hard.

In the absence of research discussing clinician’s ways of giving a diagnosis, I asked people in the Exploring Pain: Research and Meaning Facebook group to give me their account of how they were given the news about persistent pain. The themes that emerged were:

  • No-one told me my pain would persist.
  • Despite surrounding myself with a broad multidisciplinary team, no-one broached the subject.
  • Pointing to the presence of supposed pathology – “you’ll need surgery”
  • “what we’re doing isn’t helping” – despite best efforts.
  • Being put into a category of people who can’t be helped.
  • No-one showed me how to live with this pain
  • Being told casually as if it were no big deal – this shouldn’t have a big impact on you.
  • I was told there’s no cure, no effective treatment and the idea is to make life tolerable but I will probably never be pain free.
  • The diagnosis of a disease was given – but I wasn’t told it was the reason I hurt.
  • You have chronic pain and there’s not likely to be a cure in your lifetime.

In my interactions with people online, both people with pain and those hoping to treat, I’ve heard a number of opinions: we should never “give up” on pain reduction; we don’t want to “kill hope”; there’s always something we can do …

Here are a few questions:

  • When do we admit we don’t have a 100% success rate for treating persistent pain?
  • Given that people with pain often put their lives on hold until there is a diagnosis and treatment plan (usually aimed at pain reduction and/or cure) – how long does someone need to put their life on hold until we acknowledge that the cost of waiting outweighs the uncertain benefits of pain reduction?
  • Is this a decision we as clinicians should make? If it’s a collaborative decision, do we provide people living with pain an unbiased and neutral view of their options?
  • Fundamentally, do we fear living with pain ourselves, and does this in part fuel our desire to keep treating?
  • What do you think it’s like for a person living with pain to never be told that this is reality? Because people will blame themselves (for not trying hard enough), blame their health professionals (for not looking hard enough), blame the system (for not funding enough) – when actually there is no secret stash of treatments for people who are “good enough” to get them.
  • If someone is told “chances are high this won’t resolve quickly, if at all” does this mean nothing will ever change? Or simply that we’re giving permission to ourselves and the person to find ways to have a meaningful life with pain? What if we conveyed the reality that currently there may not be a way to reduce pain, but this doesn’t mean it will be forever – and in the meantime we can work together to create a life that is fulfilling?

I guess the sad thing for me is that even though we’ve had persistent pain management programmes available in various forms since the 1970’s, with the flush particularly evident in the 1990’s and waning ever since, people are still not given the opportunity to have good support while learning how to live well with pain.

Because until we have at least a 90% success rate with our treatments for persistent pain, I think we need to be humble and admit these approaches are still needed.

Toye, F., Seers, K., & Barker, K. L. (2017). Meta-ethnography to understand healthcare professionals’ experience of treating adults with chronic non-malignant pain. BMJ Open, 7(12), e018411. doi:10.1136/bmjopen-2017-018411

Tough topics to talk about


I was involved in a Facebook discussion about intimacy and sexuality and pain, and I was struck at how tough people find it to raise this kind of topic with a new person seeking help. So… I thought I’d do a series of very brief, very introductory talks on ways I’ve used to broach tough topics.

Before I begin, though, I’d like to frame my discussion by sharing my “therapy viewpoint” or the values I try to integrate in my work.

  1. People are people, so it’s OK to be a person too. What I mean by this is that therapists can sometimes feel they have to be “perfect” and know everything and say the right thing and never fumble around for words… And as therapists we can, as I’ve written recently, “other” the people we’re trying to work with. Othering is where we identify the other person we’re communicating with on the basis of their differences from us – and may inadvertently elevate the characteristics we have – while using those other characteristics to define the other person in terms of what they’re not. When I think about being a person, I mean that while I’ve learned a lot, listened a lot to stories, had my own experiences and keep learning – in the end I can’t elevate myself in my clinical interactions. I’m not the expert in this person’s life – they are – and they have had a lifetime of being them and arriving at decisions that make sense at the time, although like me they may not be aware of unintended consequences of those decisions. So, we’re equals, but with particular roles in our interactions.
  2. People usually have a few clues about what to do – but they’re ambivalent about doing them. This means that my job is to help them identify what they already know, ask to offer new ideas, and then guide them to make their own mind up about what to do next (ie, resolve their ambivalence). Sometimes I do know some things from my experience and learning and perhaps the other person hasn’t yet come across those ideas – but I need to respect their readiness to look at those options. We know that ideas a person has thought of for themselves seem to stick more than those “implanted” ones, AND the process of discovering options is a skill that will enhance self efficacy and be a lifelong skill, so the process of discovery may be more useful than any particular “answer”.
  3. Deeply personal material is rarely discussed voluntarily – people need to feel safe, not judged, and valued as people before they’re willing to share. At the same time, if we never ask about some topics, they’ll never be talked about – so as the “controller” of a clinical discussion we need to be willing to ask the tough, sensitive questions. I suspect our careful avoidance of tough topics arises from our own worries: will we get it right? will they be OK about us asking? will we know what to do if they answer? how will we deal with the emotions? is this going to take too much time out of my session? Like any clinical skill, it’s our responsibility to learn to develop self regulation so we can deal with awkward topics. Self regulation is in part about managing our personal emotional and cognitive responses to situations. Just like we had to get over ourselves when we learned examination techniques (remember your first anatomy labs?), we need to get over ourselves when we enquire about tough topics.
  4. People generally don’t make dumb decisions, they making the best decisions they can given the information at hand. Judging someone critically for having got where they have with health, pain, exercise, daily life, mood, drugs, whatever – reflects our values and our beliefs and priorities. Who says we wouldn’t make those same decisions if we’d lived the lives of the people we’re seeking? In my book, judging someone for making a different decision from me when I’m seeing them clinically suggests taking some time out and examining motives for doing this work. Nobody gets up in the morning and says “I’ll just go out and get fat today.” What happens are a series of small decisions that seem fine at the time, being either unaware of the consequences, or valuing something else. We all do this, so stop the judging!
  5. Most people with persistent pain don’t get heard. Oh they tell their story a lot – often the abbreviated one that cuts to the chase about the events leading to persistent pain and thereafter. What doesn’t get heard is what it feels like, the deepest fears, the endless questioning “am I really that bad? am I just using this to get out of doing things?” all that self-doubt, exacerbated by insensitive statements from people around them, particularly clinicians. Giving people time to talk about their main concerns, to validate that it’s OK to feel this way, that it’s common and unpleasant and real, gives people an opportunity to trust. How we let someone know we’ve heard them lies in our response to what they say: reflecting your understanding of their story, pausing to allow the person time to think and express themselves, and summarising the key points to check out that we’ve heard them accurately, these are skills we can develop.

I’m sure I have other values woven into my practice, but these are my key ones. Being real, nonjudgemental, respecting the person’s own capabilities, giving people time and bearing witness to their story, and getting good at sitting with my own discomfort – not the usual kind of skills you learn in undergrad training!

So over the next few weeks I’ll post some brief videos of some of the ways I approach tough topics.

BTW if you’re in Melbourne (or nearby) this is the course I’m running with the amazing Alison Sim – all about communication!

Seminar – “Better Communication For Better Outcomes”
Date: Sunday, 17 March 2019 from 09:00-17:00
Featuring: Bronnie Lennox Thompson and Alison Sim
On Behalf of: Beyond Mechanical Pain

“Spend a day exploring the value of communication in a clinical setting and how we can implement better ways of communicating with your clients:

◾ Motivational Interviewing 
◾ Cognitive behavioral therapy 
◾ Acceptance and Commitment Therapy (ACT) 
◾ How we define “success” in the clinic 
◾ Functional outcome measure to assess our client’s progress 
◾ Workshop style activities to practice implementing some different communication approaches “

FB Event: https://www.facebook.com/events/242714736618057/

Booking Page: 
https://www.trybooking.com/book/event…

Cost:
Students – $165
Other Practitioners – $330


Ways to avoid “othering”


After my last post on “othering” I thought I should write something about what we know reduces the distancing that othering produces. To refresh your memory, othering is what happens when we identify positive characteristics about ourselves and simultaneously identify the absence of these positives in another person. Othering is a common part of any interaction but it seems to become less helpful as views become more polarised.

Lehti, Fjellman-Wiklund, Stalnacke and colleagues (2016) describe “walking down ‘Via Dolorosa'” as the “way of pain and suffering… from primary healthcare to [a] specialty rehabilitation clinic.” This depiction also captured the way gender and sociocultural context influenced that journey: chronic pain is a ‘low status’ illness (especially compared with high status diseases like cancer, heart disease, orthopaedic problems), while those patients with higher education and similarities to treating clinicians were viewed as “easier to interact with”. This study provides an insight into the norms expected as part of “being a proper patient – ready for change”.

Norms are a part of culture, assumptions about what “is done” in a particular context. Just as health professionals learn to “be professionals”, people seeking help for their health are also expected to behave in certain ways. Othering is, as I’ve indicated above, a normal or common part of interactions – some authors suggest we need an “other” in order to for our self to “know itself and define its boundaries” (Krumer-Nevo, 2012). At the same time, once the “other” is identified in less positive terms than “self”, it’s far easier to distance oneself from the other person.

One step towards reducing the distancing between “us” as health professionals and “them” seeking help is to create moments of “belongingness”. What this means is using overt means to help people feel welcome. In New Zealand, this may mean ensuring signs are written in both Maori and English. For people with pain, it may mean explicitly indicating to people with pain that it’s OK to stand up and move around during an initial assessment.

Another way is to raise the idea of the person living with pain as an expert. “Expert?” I hear you say…Yes, expert in “what it is like to be this person living with this pain in this context”. For us to demonstrate our understanding that the person living with pain is the expert on his or her experience, we need to provide safe and welcoming opportunities for the person to tell us what it is like. Narrative medicine, if you like.

Tonini and Chesi (2018) used Charon and Remen’s definition of narrative medicine “a way of dealing with the disease through narration, aimed at understanding the complexity of the patient that will no longer be seen as a set of objective data but as a unique individual with needs” in a study of the stories given by people living with migraine. The stories were of people with a chaotic narrative where migraine was a mystery, full of disorientation and few solutions, moving through to restitution where knowledge and efffective treatment allowed the person to progress. Other narratives were “stable” leading to improvement in understanding and management, and regression, where people gave up and remained disoriented.

How might this help us reduce our sense of “othering”? In one way, learning to hear what people have to say should be fairly simple for health professionals. We’re trained to listen carefully. But what we’re often focusing on is some sort of diagnosis: “what is going on here, what’s going wrong, what’s the pathology?” Hearing another’s narrative is a different process: this involves empathising with, understanding the journey from feeling unwell to seeking help, beginning to acknowledge the similarities between this person and ourselves. How might we respond to illness if we were faced with the same circumstances? the same prior history? the same choices?

Lajos Brons, philosopher (Brons, 2015), argues that charity, or the “reasonableness argument” could help us to deal with othering. Reasonableness is an assumption that the other person has rational, coherent, and true reasons for doing and saying what they do – even if, at first, we may not discern the underlying reasons. By invoking a charitable interpretation on another’s actions, we are in turn asked to question our own preconceptions, our assumptions about the reasons the person did what they did.

Imagine that kind of humanity being brought into our judgements of people who are apparently “lacking motivation”, or “seeking secondary gain”, or “noncompliant”?



Brons, Lajos. (2015). Othering: An analysis. Transcience, 6(1), p. 69 – 90

Krumer-Nevo, M. (2012). Researching against othering. Qualitative inquiry and the politics of advocacy, 7.

Lehti, A., Fjellman-Wiklund, A., Stalnacke, B.-M., Hammarstrom, A., & Wiklund, M. (2017). Walking down ‘Via Dolorosa’ from primary health care to the specialty pain clinic-Patient and professional perceptions of inequity in rehabilitation of chronic pain. Scandinavian Journal of Caring Sciences, 31(1), 45-53.

Tonini, M. C., & Chesi, P. (2018). Narrative medicine, an innovative approach to migraine management. Neurological Sciences, 39(Suppl 1), S137-S138.

Othering


When we look at someone else, we first start by identifying the differences between that person and ourselves. It’s only later that we spend some time identifying the similarities between ourselves and that “other”.

There’s a problem in pain management today. It’s this: too few of “us” are “them” – by which I mean, there are too few people who identify as living with persistent pain working with people who are seeking help for their pain.

“Why is this a problem?” you ask… Well, it’s because it’s far too easy for “us” healthcare providers to forget that persistent pain affects people just like us. Yes, I know the stats: lots of people with persistent pain are multiply disadvantaged by socio-economic status, gender, ethnicity, age, multiple morbidities. But – and this is important – persistent pain doesn’t discriminate, but disability and distress might.

Othering was first brought to attention by Simone de Bouvier. de Bouvier was interested in the way women’s voices were hidden and often compared with men’s voices. “Why”, said men. “Are women not like us?” The answer was evident: women are not men. And in establishing that women are “other”, or “not men”, those dominant voices were able to not only elevate their own voices to prominence, but also minimise and trivialise the words of women.

There are, according to Lajos Brons, two main forms of “othering” – crude, where the assumed differences are stated; and sophisticated, where the assumed differences are stated – and seem reasonable. Let me give an example. It seems reasonable that people seeking help for their pain are needing something they don’t have. And the people they seek help from (healthcare professionals) have that something. Sensible, yes?

“What’s the problem?” you ask. Well, it’s because alongside noticing the difference between the person seeking help and “us” who might have some answers, we also begin to distance ourselves from “them”. And in doing so, we begin to dehumanise or consider that person to be different and somewhat less than us.

I don’t want to accuse readers of stigmatising people who live with pain, so let’s take a moment to unpack what I’m trying to say.

When we talk about someone who is experiencing pain and having trouble with it, we begin by trying to work out what’s going on. In the very best circumstances, we create a “third space” where we can meet one another on an equal footing – both focusing on “what’s going on here”, and neither one assuming a superior position, because while “we” the healthcare professional, might have lots of knowledge about the various factors that could be contributing to this person’s situation, “we” actually know absolutely nothing of this person’s reality, their experience. Meanwhile, the person seeking our help is the expert on what life is like with their pain, their worries, their strengths, their supports, their vulnerabilities. So we meet in the middle, and collaborate, to try to work out how we can develop something new.

Sadly, that space can be muddied by a whole lot of things. We might bring our assumptions about the “other” – that they’re afraid, they need information, they want whatever solution we provide. The person might bring their fear of being misunderstood, their memories of the last time someone “tried” to help, perhaps their idea of what we want to know. We may end up talking past one another.

Let’s see what we can assume about the person in front of us. We might think they just need to know their pain is “an output of the brain” and that “hurt doesn’t equal harm”. We might spend some time educating that person about neurobiology. We might think they need exercise. They need to lose weight. They need do more mindfulness. They need to go back to work. And so our plans for “them” are set in motion. None of these things are bad or wrong – except when we think of the person needing these things before we’ve taken the time to hear what they really want.

What does the person want? Probably like many people, they’d like someone to listen to their perspective. Then they’d like to have some daily practical problems solved: perhaps knowing that they’re not harming themselves. Then maybe some sleep management. And perhaps some time out from people telling them what to do. And maybe some explanations – but only once we’ve taken the time to listen.

“Othering” is one way health professionals maintain a professional distance. By knowing that “we” already do these things, we can feel good about what we offer “them”. But I’d like to ask: how many of us have daily, weekly, monthly goals? How many of us have set them with the SMART acronym? And how many of us have our days timetabled to make sure we do all the things expected of us? What if we have an off day? Is it OK or do we have to explain ourselves? And how many of us also live with persistent pain? I think more of us live with pain than we’re honest about…

I’ve heard “us” talk about “them” and it’s not pretty. “They” need to be more goal-focused, more persistent, more relaxed, more revved up. “They” are ‘non-copers’ anyway. “They” have always needed help for everyday life. “They” have disorganised, chaotic lives.

I wonder what would happen if “we” spent some time checking in on our assumptions about “them”? Would we find ourselves mirrored in the people we try to help? I think we would – and it might help us to remember that we’re guides, coaches, and cheering squads, but we’re no better, no worse, and just as human as “them”. Oh, and some of “us” might even be one of “them” living with pain every day….

Brons, Lajos. (2015). Othering: An analysis. Transcience, 6(1), p. 69 – 90.

de Beauvoir, S. (1949): Le deuxi`eme sexe, Paris: Gallimard, 1976.

How are you going with your resolutions?


It’s seven days into the new year, and if you’ve made New Year’s resolutions I’d like to bet that it’s around now that your resolve is starting to fade… Don’t worry, I’m not going to nag! I am going to point out just how difficult it is to stick with a resolution, goal, action, new habit – whatever you call it.

And take a moment, if you’re a health professional. Just stop for a moment and think about the resolution, goal, action, new habit you’ve just set with your last patient. What are the chances that person will stick with that goal for the week?

Add in the complexities of, perhaps, competing goals or actions set by other clinicians seeing that person concurrently. The thought records, or mindfulness practice, or the planning and prioritising and pacing. Add in the usual daily life activities that need doing: the washing, cooking, shopping for groceries, paying the bills, filling the car with gas, spending time with family (not just any old time, but quality time). And work. And remembering to take medications (even the ones that make you feel drowsy or nauseous).

And not sleeping, finding it hard to rest because pain gets in the way.

And guilt perhaps because why is this person not getting better?

Is it any wonder that the people we try to help seem “unmotivated”? Or that they appear not to be “adherent”?

I keep coming back to something that bothers me about our attitudes towards the people we try to help. There continues to be a sense of “them” and “us”, with “us” being all that is good, proper and right, and “them” being, because we’re humans who like dichotomies, the opposite. After all “they” are seeking help from “us” which automatically puts “us” in the authoritative position.

Now before I get harangued by people saying “oh but not me”, I wonder what it would be like to record yourself in conversation with your colleagues. You know the time at your breaks where you meet around the water cooler or the coffee pot, and you do a mutual moan about work. Check in with your discussion: how do you refer to the struggles of the people you see? Is there a chance, even inadvertently, to use a “should” or “must” word or two? Do you ever think not just about the things you do with the person you’re working with, but the things other clinicians are also doing?

Enough finger pointing. What can we do to (a) shift our own attitudes and (b) help the people we see stick to the things we hope will help them?

Attitude shifts

It’s a tough one. Shifting an attitude is difficult, in part because we don’t recognise we hold attitudes because they seem “normal” or commonplace – and the more ingrained or deep-seated they are, the more difficult it is for us to see them. Attitudes are complex – possibly partly based on memory and partly generated in the moment-in-time (Albarracin & Shavitt, 2018). They also change with difficulty – being in contact with “others”, for example, has been shown to influence attitudes positively, while even imagining positive contact showed about 14% of participants were more likely to explicitly state positive attitudes (Miles & Crisp, 2014). Overall, changes in attitudes based on an intervention or a message seems to have a small effect (d = 0.22) – but these seem to be quite durable changes.

But something affect our attitudes: if we argue for our beliefs, we’re likely to become more stuck in our original beliefs, we add new information to our explanations but don’t readily throw out old information. To shift attitudes, new information needs to provide a “causal alternative” to explain our mental models.

OK, so changing our own attitudes is tough but we can counter the stickiness of our attitudes by considering a few things:

  • Values – linking specific actions to important values helps us to shift our attitudes. For example, we could begin to value why we started to work in health: was it job security? desire to help people? because people are constantly changing and different and it’s an exciting intellectual challenge? Whatever the value, we can begin altering the way we act towards the people we see to embrace the similarities between “them” and “us.
  • Goals – we all vary in the level of general action we’re in. We range from being focused and both moving and thinking quickly to being completely inactive (such as when we’re asleep and not dreaming). Research has shown that if we want people to consider a new attitude, we need to frame this in the context of “being active” (Albarracin & Handley, 2011). Perhaps we need to think of the active part we play in pain rehabilitation – and consider the effects of our attitudes accordingly.
  • Language – metaphors are persuasive, and seem to affect the way our attitudes are formed as well as what we do about them. Metaphors provide a way for us to become more psychologically distant from a concept, or more aware of complex psychological constructs. We can use metaphors when we think about how we want to work with people: are we ‘advisors’ or ‘coaches’ or ‘instructors’? Do we work collaboratively – or do we expect obedience? Do we have a partnership, or do we “direct” treatment?

Helping people stick with actions/goals/new habits

There have been mountains of research papers on behaviour change within a rehabilitation context. We’ve all been drilled on the idea of SMART goals (whatever the SMART acronym is meant to stand for!). We are exhorted to “set goals” from the first visit, and in some situations (New Zealand’s ACC rehabilitation process for example) obligates us to “set goals” which then provide a marker for whether treatment has been successful or not. Problem is, as Gardner, Refshauge, McAuley, Hubsher, Goodall & Smith (2018) found, we tend to set goals that we want, in collaboration with the people we’re working with, yes, but not necessarily the goals the person wants. In fact, their study showed that the treatment orientation of the clinician (all physiotherapists in this instance) predicted the degree of involvement from the person, with those therapists holding a stronger biomedical model being less likely to incorporate the person’s own goals.

Now here I’m going to put some of my clinical experience to work rather than focusing on research, though I hope that what I’m suggesting ties into researched ideas! Locke and Latham (1990) are the godfathers of formal goal setting theory, albeit mainly in an organisational development context, however they have provided much of the information we use when working with the people seeking our help. If you’re looking for more information on goal setting, you should probably begin with their material.

What to try:

  • Begin with the end in mind. What does the person want to be able to do? Be wary of goals incorporating things no-one can completely control, such as “be able to win a race” – because someone else, on that day, may be faster that this person. Similarly, I’m wary of goals that talk about “pain-free” or “without flare-up” because we’re not always going to achieve this. Don’t forget to ask the person about what they want!! They probably don’t care too much about a 5 degree improvement in knee flexion – what they want to be able to do is go up and down stairs.
  • Check out importance and particularly confidence when it comes to goals. A goal that’s unimportant will likely fall out of someone’s brain because it doesn’t matter. A goal that’s too challenging will equally be avoided (often not on purpose but because we don’t really like thinking about things we fear we’ll fail at). If the goal isn’t important – tap into values and why it might matter to the person. Change the goal if the person can’t come up with a compelling (ie emotionally resonant) reason to do it. Build confidence by scaffolding support around the person – how can you make it so that the person feels they can be successful? Begin with their ideas first so you build on their sense of self-efficacy.
  • Generate actions to do rather than goals to achieve. Actions are done or not done. Dichomotous. Goals may or may not be achieved depending on a whole bunch of factors. Make the things the person needs to do simple and yes/no.
  • Reminders or cues help. It’s easy to forget to do your pelvic floor exercises after birth, right? But a whole lot easier to remember when they’re tied into every time you use the toilet! Tie the action to an existing habit like when you’re waiting for the jug to boil, you can do your mindfulness. When you’re cleaning your teeth is a good time to do some squats (try it!). Use a cellphone appointment reminder. Record when the action is done. Set a specific time of day – ahead of time.
  • Tracking actions helps keep on track. Graphs are great! Seeing your progress is reinforcing. But make this process easy – can it be done on the phone? Can it be recorded in a simple notebook? Check up on progress often. Problem solve when things don’t go the way you hope.
  • Problem solve the factors that might interfere with doing the action ahead of time. This might mean posing scenario’s – what would happen if the weather was bad? What would you do if you had visitors? What might get in the way of doing this? What could you say to the person who says “Oh come on, you can leave it for today?”
  • Have days off. Absolute goals that are very specific and must happen every single day are likely to fail, and then we fall into the “what the hell” effect – oh I didn’t do X, so what the hell I might as well not do anything. I recommend for daily actions, that we have two days a week where they don’t need to happen. You might want to plan for five walking sessions, and do them all in the first five days – and then have two days off for good behaviour, or even decide you’re on a roll, and do two extra days. Whatever, the person wins because they’ve achieved the original action.

There is no doubt that changing habits is tough. It’s even tougher when there are a lot of changes to implement. And even tougher still when the therapist sits in judgement of the person who is trying to juggle everything while not being at full capacity. I wonder if we as therapists could begin to view our work with people as a truly collaborative affair, where we recognise the incredible challenges the people we see are dealing with. Maybe our New Year’s Resolution could be “how to be a better therapist”.

Albarracın D, Handley IM. (2011). The time for doing is not the time for change: effects of general action and inaction goals on attitude retrieval and attitude change. Journal of Personality and Social Psychology. 100(6):983–98

Albarracin, D., & Shavitt, S. (2018). Attitudes and Attitude Change. Annual Review of Psychology, 69(1), 299-327. doi:10.1146/annurev-psych-122216-011911

Gardner, T., Refshauge, K., McAuley, J., Hübscher, M., Goodall, S., & Smith, L. (2018). Goal setting practice in chronic low back pain. What is current practice and is it affected by beliefs and attitudes? Physiotherapy Theory and Practice, 1-11.

Locke, E. A., & Latham, G. P. (1990). A theory of goal setting & task performance: Prentice-Hall, Inc.

Miles E, Crisp RJ. (2014). A meta-analytic test of the imagined contact hypothesis. Group Process. Intergroup Relations. 17(1):3–26


Five things I learned about pain this year


  1. Our definitions of pain matter more to researchers and people who like to philosophise about pain than to people experiencing pain. At the same time, definitions do matter because when the IASP definition of pain was first established, the distinction between the neurobiological underpinnings of pain – and the experience – was clear. And this matters because neurobiology is only part of the picture. (Chekka & Benzon, 2018; Cohen, Quintner & van Rysewyk, 2018; Reuter, Sienhold & Sytsma, 2018; Tesarz & Eich, 2017; Williams & Craig, 2016)
  2. The idea of “tribes” in pain and pain management is a misinterpretation of our need to work together as clinicians because pain is complex. The old argument that we’ve omitted “the bio” because we use a biopsychosocial framework for understanding pain is, frankly, ignorant. It’s also destructive because we need one another when we try to help people who are seeking our help. And even if someone has a straightforward sprain, fracture, or whatever – that sprain is happening to a living, breathing, thinking, emoting, motivated person. If we are to break down the silo thinking in pain management, we also need to learn how to work together within an interprofessional team. This means learning to speak a common language. This also means including the person with the pain as part of the team. To think that we can ignore the person and focus only on “the tissues” means we also must agree that our contribution as health professionals could be replaced by an algorithm (Gordon, Watt-Watson & Hogans, 2018; Lötsch & Ultsch, 2018; Shluzas & Pickham, 2018 .
  3. The gap between what is investigated in research institutions and both the concerns of clinicians and patients, and implementing research findings is enormous. Accusing researchers of ‘living in ivory towers’ fails to recognise that most of our active pain researchers in rehabilitation still continue in clinical practice. The gap seems to be between funding agencies (valuing high tech, high impact research) and the concerns of clinicians (often about high value, low tech, and low cost research). There are very active discussions about “how do I use this study” on social media across the board – Twitter, Facebook, LinkedIn, blogging – and these represent possibly the most important vehicles for clinicians, policy-developers, researchers and people living with pain to break down silo thinking and begin to address the factors that contribute to the knowledge translation gap. Many discussions on Exploring Pain: Research and Meaning (Facebook group) end with acknowledgement that funding systems simply do not support collaborative evidence based teamwork (Arumugam, MacDermid, Walton & Grewal, 2018; Bérubé, Poitras, Bastien, Laliberté, Lacharité & Gross, 2018; Chen, Tsoy, Upadhye & Chan, 2018; Romney, Salbach, Parrott & Deutsch, 2018; Tougas, Chambers, Corkum, Robillard, Gruzd, Howard,… & Hundert et al., 2018).
  4. The social part of pain is receiving increased research and clinical attention – and it’s a messy area of study. Social isn’t well-defined – it can mean social psychology, sociology, culture, health systems, media, feminism, political science, legislation – anything where people interact. Social psychology studies investigate things like trustworthiness, gender effects in interactions, stigma (Naushad, Dunn, Muñoz & Leykin, 2018; Sherman, Walker, Saunders, Shortreed, Parchman, Hansen, … & Von Korff, 2018; Wesolowicz, Clark, Boissoneault & Robinson, 2018), while sociology examines diagnoses and power relationships in healthcare – things like being “too young” for a diagnosis of arthritis (Kirkpatrick, Locock, Farre, Ryan, Salisbury & McDonagh, 2018) or validating the pain of menstruation (Wright, 2018) or a diagnosis of fibromyalgia (Mengshoel, Sim, Ahlsen & Madden, 2018). It seems no accident that many of the pain problems needing “validation” occur more often in women, and fail to have “objective” signs. But social means more than labeling and interacting, it’s also about community values and ideas – and how pain is portrayed by people experiencing pain, and in the media (Kugelmann, Watson & Frisby, 2018). The way WE talk about pain, and how we talk about people living with pain. How people living with pain are portrayed and how they portray themselves (ourselves). I suspect the social aspects of our experience with pain are amongst the most complex and most potent in determining suffering (loss of sense of “who am I?”) and disability (“what can I still do?”).
  5. Finally, I am encouraged by the wealth of information being shared freely, discussed passionately, and applied in many different forms around the world. I am proud to have been associated with many different groups as we – you, me, people living with pain, us – keep this topic alive and up-front. While I am no great productive scholar, I publish few peer-reviewed articles, and in the eyes of University hierarchy I am insignificant, I believe the conversations had on social media and into the real world have an impact on how we work in the clinic. If we can achieve the things we talk about, even if we achieve only a fraction of those things, we will have helped more people than we can ever imagine. I feel so privileged to have got to know some of the greatest “lived experience” advocates for greater ‘patient’ involvement in our conversations about pain. Isn’t it time we remembered the old adage “nothing about us without us”? Social media allows us to break the code of silence – and the distinction between “us” and “them” in the world of pain. After all, many of “us” are also living well with persistent pain.


Arumugam, V., MacDermid, J. C., Walton, D., & Grewal, R. (2018). Attitudes, knowledge and behaviors related to evidence-based practice in health professionals involved in pain management. International journal of evidence-based healthcare, 16(2), 107-118.

Bérubé, M. È., Poitras, S., Bastien, M., Laliberté, L. A., Lacharité, A., & Gross, D. P. (2018). Strategies to translate knowledge related to common musculoskeletal conditions into physiotherapy practice: a systematic review. Physiotherapy, 104(1), 1-8.

Chen, E., Tsoy, D., Upadhye, S., & Chan, T. M. (2018). The Acute Care of Chronic Pain Study: Perceptions of Acute Care Providers on Chronic Pain, a Social Media-based Investigation. Cureus, 10(3).

Chekka, K., & Benzon, H. T. (2018). Taxonomy: definition of pain terms and chronic pain syndromes. In Essentials of Pain Medicine (Fourth Edition) (pp. 21-24).

Cohen, M., Quintner, J., & van Rysewyk, S. (2018). Reconsidering the International Association for the Study of Pain definition of pain. Pain reports, 3(2).

Gordon, D. B., Watt-Watson, J., & Hogans, B. B. (2018). Interprofessional pain education—with, from, and about competent, collaborative practice teams to transform pain care. Pain Reports, 3(3).

Kirkpatrick, S., Locock, L., Farre, A., Ryan, S., Salisbury, H., & McDonagh, J. E. (2018). Untimely illness: When diagnosis does not match age‐related expectations. Health Expectations.

Kugelmann, R., Watson, K., Frisby, G (2018). Social representations of chronic pain in newspapers, online media, and film. Pain, in press.

Lötsch, J., & Ultsch, A. (2018). Machine learning in pain research. Pain, 159(4), 623.

Mengshoel, A. M., Sim, J., Ahlsen, B., & Madden, S. (2018). Diagnostic experience of patients with fibromyalgia–A meta-ethnography. Chronic illness, 14(3), 194-211.

Naushad, N., Dunn, L. B., Muñoz, R. F., & Leykin, Y. (2018). Depression increases subjective stigma of chronic pain. Journal of affective disorders, 229, 456-462.

Reuter, K., Sienhold, M., & Sytsma, J. (2018). Putting pain in its proper place. Analysis.

Romney, W., Salbach, N., Parrott, J. S., & Deutsch, J. E. (2018). A knowledge translation intervention designed using audit and feedback and the Theoretical Domains Framework for physical therapists working in inpatient rehabilitation: A case report. Physiotherapy theory and practice, 1-17.

Sherman, K. J., Walker, R. L., Saunders, K., Shortreed, S. M., Parchman, M., Hansen, R. N., … & Von Korff, M. (2018). Doctor-patient trust among chronic pain patients on chronic opioid therapy after opioid risk reduction initiatives: A Survey. The Journal of the American Board of Family Medicine, 31(4), 578-587.

Shluzas, L. A., & Pickham, D. (2018). Human Technology Teamwork: Enhancing the Communication of Pain Between Patients and Providers. In Design Thinking Research (pp. 313-325). Springer, Cham.

Tesarz, J., & Eich, W. (2017). A conceptual framework for “updating the definition of pain”. Pain, 158(6), 1177-1178.

Tougas, M. E., Chambers, C. T., Corkum, P., Robillard, J. M., Gruzd, A., Howard, V., … & Hundert, A. S. (2018). Social Media Content About Children’s Pain and Sleep: Content and Network Analysis. JMIR Pediatrics and Parenting, 1(2), e11193.

Wesolowicz, D. M., Clark, J. F., Boissoneault, J., & Robinson, M. E. (2018). The roles of gender and profession on gender role expectations of pain in health care professionals. Journal of Pain Research, 11, 1121.

Williams, A. C. D. C., & Craig, K. D. (2016). Updating the definition of pain. Pain, 157(11), 2420-2423.

Wright, K. O. (2018). “You have Endometriosis”: Making Menstruation-Related Pain Legitimate in a Biomedical World. Health communication, 1-4.