summer

Those who expect moments of change to be comfortable and free of conflict have not learned their history ~ Joan Wallach Scott


I’ve been touring North America – Chicago, Toronto, Edmonton and Vancouver. As I’ve toured I’ve been listening to the stories of change and insight as different professions review their contributions to effective pain treatment. Some things change, some things stay the same – but as the quote above indicates, change isn’t comfortable nor free of conflict.

What have I found in my travels?

There’s a great deal to be proud of in our approaches to helping people who live with pain. Allied health practitioners of various backgrounds have adopted and adapted to the discoveries about how people experience and deal with their experience of pain. There’s been enormous change in our views of pain as neither a form of mental illness (or malingering, or imagination, or even simply weakness of spirit), nor a lifelong static state. Allied health practitioners of every kind know that they can contribute to helping people make sense of their pain, perhaps change their experience and reduce the distress and disability that living with pain can bring.

Disturbingly, though, I heard the exact same issues as those I face in New Zealand, when it comes to unrest and disquiet about competence, scope, and funding for effective treatments.

Disquiet because some of the different professions lay claim to certain areas of practice as “theirs”. Disquiet because there are attempts to limit access to learning about aspects of pain that are integral to the experience and management of pain. Concerns that some clinicians might be overstepping their scope when they begin to develop skills in, most notably, psychosocial aspects of our experience of pain. And disproportionate funding given to short-term (primarily) biomedical interventions without a consistent or even logical argument for similar funding levels to be applied to allied health approaches. Or worse – funding given to those working in a single-discipline approach, and loss of funding (or funding not even considered for) approaches where teamwork is a critical part of the treatment.

As a somewhat renegade occupational therapist with a MSc in psychology, PhD in health sciences, and great interest in psychosocial aspects of pain, I know that I don’t sit especially comfortably in one little box. And it was SO refreshing to find that I’m not alone in this. As allied health professionals develop knowledge and skills in a biopsychosocial and neurobiologically sophisticated model of pain, it becomes increasingly difficult to distinguish between the practice of good occupational therapists, physiotherapists, massage therapists, psychologists, nurses and social workers when working with people who live with pain.

Our aims are the same: we want to help people live good lives despite experiencing pain. Some of the ways we ALL do this are to help people reconceptualise pain as something that is not fixed but can be influenced by reducing the threat value of the experience within the context of what we view as important.

We ALL draw on learning theories, influencing beliefs and attitudes, consider contingencies and work at reducing the relationship between experiencing something inherently unpleasant and avoiding that experience.

We ALL help people set goals, work hard to achieve them, use movement and activity to help pursue what is valued and deal effectively with what gets in the way of this.

We ALL use motivational approaches, we ALL consider personal values and choices, we ALL want the people we work with to have the freedom to choose personally-valued goals and outcomes.

We ALL draw freely on the published scientific literature across all the branches of pain research – biological, psychological, and to a lesser extent, sociological. (I’d love to see far more emphasis on the social as I’m sure regular readers know!).

It confuses and perplexes me that each one of our professional groups has, at times, criticised other professions for failing to address or consider the aspects of pain experience that our particular group sees as critical. But what really perplexes me is that once another profession begins to take up the challenge of adopting and integrating learning from “outside” their original knowledge base, some people turn right around and begin to criticise that group for “working out of scope”. It does not make sense.

A discussion that I think needs to begin is to consider the merit of a specialist “certification” if you like, for those people who have taken time to learn about pain in-depth, and who no longer fit as comfortably within their original profession as they once did. As I saw so often in my travels, when we get beyond the simplistic level of learning about pain as a biopsychosocial experience we begin to recognise that the way we work with people changes over time to become so much more similar than dissimilar that our professional disciplinary approaches seem to fade away.

I know that in the years since my original training and graduation as an occupational therapist (waaaay back in 1983) I’ve done so much more learning and development that what I do now is so very different from what I did then. I’m still essentially interested in helping people do what is important in their lives. Doing, or occupation, is integral to my practice. The ways I help people achieve this (thus reducing distress and disability) has changed but my “domain of concern” (old-fashioned language for “what I’m interested in”) is still occupation, or the things people want and need to do in daily life.

The obstacles to participating in occupations might be addressed in slightly different ways, but I draw on the same fields of knowledge that I drew on in 1983. Just as I learned then that biomechanical, kinesiological, anatomical, biological, psychological, social, anthropological – and the rest – ways of understanding human behaviour informed the way I work with people, I STILL draw on those same fields of knowledge. The first three fields might have less influence now than I thought they did when I first started working in pain management, but they all contribute.

So here’s the thing: if there is so much our different professions have in common with one another, is it time for allied health professionals to work in a united way to demonstrate just how significant our contribution is to the health and wellbeing of people living with pain? Is it time to trust one another just a little more and stop the infighting as to who is working “in” or “out” of scope? Isn’t it time we looked to the people we work with and for, and focused a little more on sharing our expertise with one another? Shouldn’t we trust that if we’re interested in what works well for the people we want to help, we’ll develop effective knowledge and skills rather than thinking, like Gollum “It’s mine! It’s my preciousssssss!”

I truly thing we can do a much more effective job if we remember that while we let go of some things that we think of as “ours” we might have made just a little room to add some new skills to our own repertoire? And perhaps that change might happen more smoothly if we were more accepting of the need to let go some control and trust a little more.

5 comments

  1. Bronnie, becoming a specialist in anything, who is this for? As a ‘scope of practice’ as some professions have done, it has perhaps become too restricting. As I understand it Scopes of practice are to protect the patient/consumer, and are to ensure a baseline of skills are competent and audited to ensure a safe service to those we treat. I think you are looking for something along the lines like Neurodev therapists have done, acknowledged there is a core of skills, based some training and certification around it and now it is a domain of practice in its own right. I believe this is the way forward to develop our skills but I still think different professions have a slightlly different take on the people we see and that offers a broader view.

    1. Of course we have professionally distinct ways of viewing people and the problems we can help with, but the purpose is to recognise that across all disciplines there is more in common between what I do and what a PT does compared with the practice I might do as an occupational therapist working with people who have chronic pain vs the work I might do as an occupational therapist working with people who have spinal cord injury. “certification” to me is about recognition of fundamental skills and the similarities of practice rather than what happens currently which is to carve out areas of pain practice that “belong” to certain professions. My hope is that this would enable people like me to work with my strengths rather than being told I’m “too psychological” to be an occupational therapist, and for people like the physiotherapists I know who work in a very similar way to me to avoid being told “that’s not what a physiotherapist does”. Often these accusations come from within the same profession (eg OTs accusing me of not being occupational, PTs being accused of not being PT enough), but they can also arise from outside the profession – eg psychologists accusing me of being “too psychological”, occupational therapists accusing PTs of “addressing occupation”. I think these distinctions are unhelpful when perhaps it’s less about what we look at, and how we work with people and far more about developing a good quality relationship with the person living with pain, so that they can trust us. I guess I’m thinking of the North American “Hand therapists” group and the neurodevelopmental group yes.

  2. Interesting read. I’m a Physio who was frustrated with a particular chronic pain pt. While back in Christchurch I mentioned it to my father in law who was a Psychiatrist. He said you ever consider his problems aren’t just physical? Most profound thing which completely changed my view on chronic pain and its treatment. Great man my father in law.

    1. I agree – something we all need to remember is that people from all walks of life, and with all sorts of comorbidities and other health problems will also get chronic pain. And sometimes our response to their distress can be because of our own discomfort with something about their presentation. People can have psychiatric problems as well as chronic pain – chronic pain invades all of life.

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