Niagara Falls

You are unique, and if that is not fulfilled, then something has been lost: Martha Graham


In an era in healthcare where administrators prize standardisation, algorithms and consistency, it’s no wonder that in chronic pain management there are concerted efforts to make a standard treatment recipe to suit everyone. After all, there are common things that people living with pain need: accurate information about pain, accurate information about tissues and how they contribute to pain, assurance that pain doesn’t mean ongoing damage, and being introduced to some safe movements that don’t threaten an already agitated nervous system. There’s even a call for clinicians to use a kind of curriculum to make sure all the important bits are covered based on the individual’s presentation. This is valuable stuff!

But, I think standardisation* is both an admirable and a futile effort. Admirable because we know there are so many clinicians and patients who don’t get told much  of this information. Admirable because it would be great to know that once given, this information should make a difference to the person living with pain. Admirable because it’s easier to remember a “standard” list of topics, or a standard management approach than to generate a fresh new one every time a person comes in to see you. But I think a standardised approach (used unthinkingly) might not be the most efficient way, it could almost be futile, and here’s why.

*(note: not the curriculum for pain education, but the notion of a standard list of topics that every person with pain should have covered)

I’m a nerd. That’s right, when I get on a topic I love, I can talk for hours! I have seen the eye rolls, and that subtle slump that tells me that I’ve gone on too long. I think there’s a very fine line between being enthusiastic and being too intense, particularly when it’s a topic I love but maybe the other person is less enthralled with. I know I’m not alone in this enthusiasm (thank goodness!) but I also know that I need to be aware of all those cues that tell me when someone has had enough and I’m boring them. If I want to do more than lecture, I need to go about my conversations in a different way.  I have to actually converse not harangue!

Conversations, especially where one person is knowledgeable about a subject and the other isn’t, are really guided discoveries. A guided discovery is where one person asks a question and the other person, who knows the answers, is able to answer. The questioner listens because he or she wants to find out. Various skills underpin conversations – mirroring body language, use of gaze (looking at the person, looking away), using metaphors and those little “listening cues” like “uhuh” or “mmmm” or “tell me more”. The thing about conversations is that although one person is finding out about the other, in fact most times both parties will learn something new.

We’d expect the person asking the questions to learn something new, but the person responding? How do they learn something new? There’s quite a large body of research that considers conversation to be one of the main ways humans develop meaning, and that these meanings are then reflected in the way we perceive events and act on them (Strong, 1999). In other words, as we converse with one another we develop a shared understanding of the subject under discussion – or at least it’s possible to do so.

This view is part of a social constructivist view of reality.  Strong’s paper states that people living with chronic pain experience suffering when “chronic pain sufferers and others are engaged in conversations that yield no differences in meanings for the participants” (Strong, 1999, p. 39). In other words, when one person is not heard, or the conversations they have with others don’t influence the beliefs or meanings they have, the conversations themselves contribute to suffering.

It’s not hard to see that if one partner in the conversation isn’t really listening; or if the questions being asked are only done to confirm a prior belief; or if the person answering doesn’t think the other is listening – well, neither person will change his or her understanding. And I think this is what we risk if we use a standardised way to provide information to people.

I can see that instead of being a conversation in which both parties learn, “educating” could become an opportunity for one person to lecture the other. Now I know this isn’t the intention of pain neurophysiology education. I know that it’s intended to be conducted within the framework of genuinely wanting to help the person living with pain view their pain as less threatening and less mysterious.

I said before that I think standardising a “pain education” for people living with pain might be futile. This is why: when each person has a unique understanding of their body, their pain and their life, and when they’ve had a unique pathway to getting to see a clinician, they’ve probably also had any number of unique conversations in which their understanding of their pain has been changed. They’ve taken a bit here, and a bit there. A piece of this and a dab of that. And then they’ve infused this with their own experiences and arrived at their own theory for why they have pain. Each one of those thoughts and beliefs and attitudes needs to be revisited in the light of new information. This is not something that will shift with just one “info dump”.

What I’ve learned from motivational interviewing and case formulation (thanks psychology!) is that until the person is ready to hear what we have to say, they’ll pick up on the parts of what we say that they want to hear. What this means is that we need to give them the respect they deserve for making their own theory for their pain, and we need to listen to what it is and how they’ve developed it. It makes sense to them. And we need to ask for permission to introduce a new idea. If we jump right on in there without being given permission I know how that will go down! In a few cases the person will be absolutely fine with it: they were ready to hear something new. But in many cases, we’ll be generating resistance because we’re challenging something the person has learned for him or herself.

I think we also need to recognise that people pick and choose the bits of information that resonate for them. This means their understanding of pain is unique to them. We know that reviewing existing knowledge in light of new information is a really good way for students to develop a deep understanding of their subject matter – the same occurs for people learning about their pain. By gently guiding people through both their current understanding, and then through a combination of information and experience, they will draw their own conclusions about what this new material means. Our “education” needs to be a guided discovery together with the person so they can make sense of their experience in the light of new information.

Some resources for guided discovery: – teaching physical education

Socratic questioning – Padesky

Priory – guided therapy

Psi – Balancing thoughts

Strong, Tom. (1999). Macro- and micro-conversation in conspiring with chronic pain. Journal of Systemic Therapies, 18(3), 37-50.

4 comments

  1. Hi Bronnie

    I think your link above to our recent blog post misrepresents what our post was about. You suggest that there is a call to “make a standard treatment recipe to suit everyone” and to “use a kind of curriculum”, linking to our post as an example of the ‘admirable but futile’ effort.

    However, the post on NOIjam entitled “Building a simple curriculum” was not about using a curriculum, but about building a curriculum – building a customised, unique, individual curriculum for the unique, individual sitting in front of the clinician.

    Our post suggests “As educators, we need to be ready to adapt – adapt the message, adapt the delivery style and adapt the timing and so on – this becomes a bit of a didactic dance as we adjust continually to the responses of the patient, making sure that we have them on board as we mentally check off each KEPI.”

    Surely, this is as far from “standardisation” as one can get.

    Central to our philosophy at NOI are the ideas of ‘education for all’ and individual adaptation of the educational message. We have actively fought against notions of standardisation, algorithms and standard ‘packages’ of education. Unfortunately, the attempt at the standardisation of teaching people about the biology of pain has been far from futile (although the results may be) with many individuals and groups out there teaching a kind of dumbed-down Explain Pain in recipe format. Furthermore, I would contend that there is nothing admirable about this attempt to standardise pain biology education at all.

    We have also worked hard at encouraging health professionals to extend their skills as communicators and educators so as to be better able to deliver effective Explain Pain, based on the needs of the individual in front of them, not on some rote flowchart. This included bringing to Australia Professor Mark Jensen to talk about hypnosis and motivational interviewing, and Assoc Prof Kevin Vowles to introduce ACT, at our EP3 events.

    In many ways, it seems that we are on the very same page, which makes your linking to our post as an example of the admirable but futile attempt at standardisation of chronic pain management, somewhat confusing in an otherwise fine post.

    My best
    Tim

    1. Thanks for taking the time to comment, Tim. On re-reading I can understand how it could be misinterpreted! I certainly didn’t intend to suggest that the “curriculum” or KEPI was ‘futile’. What I am concerned about is the notion that having given someone “information”, a clinician thinking that this is sufficient. They can think that simply by providing accurate education, this will have changed a person’s understanding and beliefs/attitudes. Like an algorithm in which people are sent along a “care pathway” that’s intended to ensure everyone gets “enough” information or care, but may not actually reflect the person’s unique view or their unique needs and priorities. Like you’ve pointed out, the “standardisation” results have been futile … with a dumbed down recipe format. THAT’S my concern! Dumbed down often means simplified, and recipe-like “this is what you need to know” rather than responding to the discussion between two people.
      I hope my post is pitched is at the place preceding the mental “KEPI” that you’ve suggested. In the eliciting a narrative, or guiding the discovery of why this person is presenting in this way at this time, and before deciding what can be done to reduce distress and disability.
      Pain education curricula are being developed and used in primary care, by GP’s, physiotherapists, occupational therapists, nurses, massage therapists, osteopaths, chiropractors, myotherapists and many people in between. Examples include the original Back Pain Booklet (developed in the UK), and there are many more! The problem is exactly as you’ve said: dumbing down, following a recipe, believing that a cookie cutter approach is as good as a flexible and nuanced approach that develops out of really listening to, and hearing the person’s main concerns and how they’ve developed these.
      I do think we’re on the same page, and I hope my amended post is a bit clearer!

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