Developing a shared plan

Last week I introduced you to one way I use to develop a shared understanding of the many factors influencing how and why a person seeks help for their pain.  The person and I work together to understand his or her perspective. I use a range of open-ended questions and reflective listening to guide our discovery of how his/her pain affects life and emotions.

Some points to note:

  • I don’t try to give explanations at this point – explanations will influence what the person says to me, and may inadvertently shape or change what he or she says without necessarily changing his or her beliefs.
  • I’m not trying to make any diagnoses either. A diagnosis is just a short-hand way of lumping a bunch of symptoms together. Great for research, and great for when we have a clear treatment, but a diagnosis tells us nothing about how the problem is affecting this person at this time. And in pain we’re always looking at the person and his or her experience, because even if we successfully get rid of the pain, the person will have learned something through the experience and this will influence the person in the future.
  • I’m informed by what we know about pain from research, so I’m constantly probing and looking for the relationships between factors we know will affect the person. Note that I’m not looking for tissue-level influences, but rather I’m investigating at a “person” level. This means I’m looking at psychological and sociological processes. I’m not ignoring those tissue-level factors, but I’m placing those off to one side for the moment. There are a couple of reasons for this: the first is that I’m probably not going to directly influence tissue-level factors. I don’t lay hands on people. I don’t give drugs. The second is that the person isn’t likely to be aware of those factors. They know much of their own experience (not all – but we’ll come to that), and experience and perception are the most potent drivers of what a person believes and therefore does.
  • I try wherever possible to flesh out my interview with additional information. This might be from questionnaires, or observing, or clinical notes from other people. And yes, I incorporate this information with the full knowledge of the person – in fact, they’re part of the process of integrating this information.

What do I end up with?

A spaghetti junction! A diagram that looks a lot like this:

formulationThis diagram is a pretty simple one, when you think of all the factors that could be involved – and in this case, I’ve made it much clearer than my usual scribble!

At this point I have a series of hypotheses to explain why Gerald is in this state. Together with Gerald, we’ve established that there could be some fear of pain, and in particular, fear that Gerald won’t be able to cope if his pain goes up and doesn’t settle. Gerald has also identified that he can feel helpless at these times, because he doesn’t know what else to do to manage his pain. He believes he’s getting unfit, and that’s adding to his feelings of frustration. He doesn’t want to go out with his mates because he’s irritable. He tries not to let his wife know how he’s feeling to protect her, but this adds to him feeling isolated. He doesn’t want to go back to work, not because he’s not motivated, but because he’s afraid he’ll let them down and this will add to his guilt. He doesn’t think his case manager understands this.

I could ask Gerald to list his main concerns and use these as a guide for my treatment outcomes, but I’ve recently started using a different approach. I’ll ask Gerald what he would be doing differently if his pain wasn’t such a problem to him.

Bronnie: Let’s imagine for a minute, what would you be doing differently if your pain wasn’t such a problem?

Gerald: Well, I’d be back at work, for one thing.

Bronnie: OK, and would you think you’d be back at work full time, or ease your way back in?

Gerald: Well, I think it would be sensible to ease myself back in because it’s been a while and I’m out of shape. Better to know I can do it than have a go and fail.

Bronnie: Great idea. What else would you be doing differently if your pain wasn’t such a problem?

Gerald: I’d take my wife out for dinner, it’s been hard on her while I’m so laid up and grumpy.

Bronnie: What’s your main concern about going out to dinner with your wife right now?

Gerald: I can’t sit long enough to enjoy a meal out. It all seems so hard, to get into a car, and drive to a restaurant, and sit there for three courses. I’m just too sore to do it.

Bronnie: So going to a restaurant and sitting to get there and while you’re there is going to increase your pain?

Gerald: Yeah. Is it worth it? What if it doesn’t settle? I can’t sleep and then the next day I’m shattered. I don’t think it’s worth it.

Bronnie: OK. Is there anything else you’d be doing if your pain wasn’t such a problem for you?

Gerald: I’d be going out and seeing my mates, going fishing and 4 wheel driving. I miss that. There’s no way I could do that right now.

Bronnie: What’s your main concern about going fishing, and seeing your mates at the moment?

Gerald: I’d be ready to go home before they’d even started. They’d get fed up with me slowing them down. And casting is really hard on my neck.

Bronnie: So to sum up then, it seems like there are some things you’d love to be doing, but reasons you think it would be better not to be doing them right now. If we go through them, you’d love to go back to work, but you’d like to do it gradually so you can get in shape again, and so you know you’ll succeed. You’d love to take your wife out for dinner, but the whole dinner thing feels too hard, and you’re worried that your pain will get out of hand and you won’t be able to sleep. And you’d really love to get back out with your mates again, and go fishing, but right now you think your mates would get fed up with you because you’d want to leave too early, and you wouldn’t be able to cast without setting your pain off. Does that sound about right?

Gerald: Yeah.

Bronnie: I think there are some things we could begin to work on so you feel more confident you can handle it when your pain levels go up and down. And I think we could work on some physical things that could help you feel a bit fitter, more able to do things for longer. And finally, I think it would be great if we could help you and your wife connect a bit more, perhaps not yet at a sit-down restaurant, but perhaps there are other ways this could happen. What are your thoughts? Is there anything you’d especially like to look at?

What I’ve tried to do here is identify the underlying reasons Gerald isn’t doing things. While pain appears to be the problem, it’s not the pain it self but the fear of possible effects of pain that haven’t even happened yet that are really stopping him from doing things. And this is adding to the misery of having neck pain.

By giving Gerald the chance to tell me his dreams, we’re going beyond “I need to get rid of my pain” and into the reasons for living in the first place. People don’t just live to get rid of pain, they live to have lives full of meaning, let’s not ever forget that.


  1. As Gerald’s best mate, I’m OK with asking him along – early start of course. And sorry about the short notice.
    See, I just can’t stand the downer he brings upon the outing. It’s draining, and I fear his attitude is contagious.

    1. Completely understandable! I’d be suggesting some other ways to get together – he might like to go watch some of their past hunting, fishing videos for a laugh, or tell pork pies about the size of the last catch! Gerald might want to go out a couple of times by himself for short periods rather than the whole time. He might see if the boys want to meet up at the pub for a few. Lots of options!

  2. There it is. It’s the fear of the return of the pain. I live pain free now thanks to time, wonderful PTs – docs – etc. But slipping, tripping, picking make me so nervous all the time because of the fear of re-injury and the pain associated with living in pain for the last 2+ years. My new PT always asks “does it hurt” to which I always reply “no” but in my head I am sometimes still saying “no, not yet” from a fear standpoint.

    At the beginning before the 2 should surgeries I had no pain while doing activities, only after a few hours or days. Eventually it got to the point of every single waking moment was painful. I am fearful that if I do something to it now, I won’t know for a few days and that will be a few days too late.

    1. It takes simply ages to become less anxious about the pain increasing again! And I can imagine how difficult it must be to not know whether something will trigger it, or whether it will be fine. Best be on the safe side and not do anything to upset it, but that means life gets really small and cramped…
      I have some suggestions for you, but I’m a bit reluctant to do this over the internet without knowing more about you and your situation. What I do know is that you’ve managed to get by when your pain was really bad, so you DO have resilience and strength to get through even tough times. There are some ways to test yourself out to see whether something will do it without overwhelming you, I usually suggest starting on something little, something that doesn’t make you cringe too much in anticipation of the GRAB of your pain. Perhaps walking along the footpath – but this time, bring your fear along with you. Imagine it’s a stray dog that’s coming along on the walk with you. If the pain doesn’t kick in, you’ll have learned something. If it does, you know you can deal with it because you have done before. You KNOW it settles down again, although it can take it’s time (lazy-ass pain, I call it!). You probably know your early warning signs too. And I’ll bet you know what to do to settle your pain down when it just begins to niggle. Maybe that’s by breathing deeply and slowly. Maybe that’s by being kind to yourself for a day. Perhaps it’s by distracting yourself. You’ll know what’s worked before. Then think about how you went about your walk – how far did you go? How worried were you before you went? Could you go a little further? Or perhaps go somewhere more interesting? Or do some relaxing stretching and breathing before – and after – you go. It’s even better if you can rate your “yuckiness scale” before you do something like this – how yucky is it out of 10? Then rate it again once you’ve finished it. Is it still as yucky? More yucky? Less yucky? If it’s more yucky, ask yourself what it is about it that makes it so yucky? so often it’s not the pain itself, it’s feeling worn out from the stress of doing something that might increase your pain.
      I wish you well in your journey with pain, and btw I LOVE your blog!! Reaching that point, the tipping point or turning point is such a great place to be. You’ll do it, I know!

      1. Your reply is the most amazing thing. Thank YOU for even taking a few minutes to read my blog. That means a lot to me. I saw Scot today and he said he was glad that I was reading your stuff, fear is truly my biggest hurdle right now.

        The jist – injured my posterior labrum likely doing a push up challenge after my tipping point. Ignored for so long it had a fluid filled cyst that went through the labrum. Had surgery and it was successful. Was restraining a child at work (special ed teacher) and he re-torn it. 2nd surgery 6 months after the 1st one. Double the posts, tear, and stitches in the 2nd surgery. Now 15 months post the second surgery. Spent a long time just doing range of motion and not enough doing strength. Now on the strength path.

        I’ve been talking to myself a lot in class – I do something called barre3. When it does not hurt I tell myself it doesn’t hurt. When working through a new range today it felt really tight and my thumb & fingers got numb, so now I know I can try new things without pain but learning to understand what my body is telling me in new ways (not pain).

  3. How awesome! Barre3 must be some kind of dance class? I like your idea of reminding yourself that it doesn’t hurt when it’s not hurting. And thinking about it as tightness rather than pain is good too. If you like using mindfulness you can always take the time to really notice where your pain is – and where it isn’t. Where’s the border between sore and not sore? And what exactly does it feel like? Deep or shallow? Hot or tingly? If you’re precise in your observation (like being really curious about it), I think that takes so much of the “OMG it’s REALLY BAD” sting out of the actual pain itself.
    Keep in touch! It’s cool to hear when people are trying things out.

    1. Love!! I like the idea of using the different adjectives instead of “painful.”

      Yes, barre3 is a mix of yoga and pilates. Very fun!!

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