For many therapists, learning the Right Way to treat a person experiencing pain means following rules. Observe this, identify that, follow the yellow brick road and end up with the right result. The problem is that people don’t always respond in the way the rules suggest meaning both clinician and patient can be confused about what to do next. While it’s normal to generate clinical heuristics, or rules of thumb, these can limit the way we approach helping someone.
I’ve been pondering this as I’m reading Villatte, Viullatte and Hayes Mastering the clinical conversation: Language as intervention. I posted last time I wrote about the problems that language can pose for us as we attend to the concepts and relationships those word generate for us rather than noticing what is actually happening right here and now. I was originally thinking of the people we work with and treat, but now I want to turn my attention to us – because we too can be imprisoned within rules that function well in one context – but hamper flexible responses in other contexts.
The rules we follow
Some of the rules we learn during our initial clinical training can be very helpful – for example, we learn that we need to attend to what people say and do; we learn to suppress our judgements about the person as “likeable” or “unlikable” (hopefully); we learn the importance of using correct terminology with one another. Other rules are far less helpful: in my case, learning that people “should” use a raised toilet seat after hip replacement (almost irrespective of the bathroom they have, the alternatives they’d already organised, or whether it actually reduced the risk of hip dislocation) meant that I tried to give the things out to people who didn’t actually need them. I quickly stopped doing that after I found too many of those toilet seats dumped on the roadside inorganic rubbish collection! And I became more sensitive to who, what, when and where. And I changed my thoughts once I read the research suggesting those “hip precautions” perhaps don’t hold up to scrutiny (for example: Schmidt-Braekling, Waldstein, Akalin, et al, 2015; Ververeli, Lebby, Tyler & Fouad, 2009).
We follow many other clinical rules – for example, we attend to certain features of a person’s presentation because we’ve been told it’s important. Depending on the model or theory we hold about the problem, we’ll attend to some things and not others.
Similarly in terms of our treatments – we’ve been told that some treatments are “good” and others not so. Some of us follow these rules very strictly – so patients are told to move in certain ways, to avoid certain movements, to do six repetitions of an exercise, to stop for a break every hour – and some of us have even been quite frustrated because the patients we’ve been advising tell us these rules aren’t working. We think “but they should”!
A good example of this is the push to ensure every person experiencing pain gets an explanation for their pain. We’ve seen the evidence showing it’s a good thing, and we’ve even learned a set of phrases that we’ve been told “work”.
BUT is this a rule we should always follow?
In some instances giving pain education is unhelpful. Times I can think of are when a person is presenting with high pain intensity and in an acute situation – or when they’re stuck with an explanation they prefer and aren’t ready to consider another, or when they have other more important concerns.
Based on what I’ve been reading, perhaps we need to consider some alternative ways of looking at this “rule”.
Here’s the thing: for some people, at the right time, and when the person is being helped to discover for themselves, learning about pain neurobiology is a really good thing. But if we apply this as a rule, we risk becoming insensitive to other things the person might need AND to whether the education has had the intended effect. For some people, it’s not the right thing – the outcome for THAT person might be seen in increased resistance to your therapeutic approach, or arguing back, or them simply not returning because we “didn’t listen” or “told me it’s all in my head”. For others, this information might be useful but not as important as identifying that they’re really worried about their financial situation, or their family relationships, or their mood is getting them down, or they’re not sleeping…
Am I suggesting not to do pain education? Not at all. I’m suggesting that instead of developing a rule that “everyone must have pain education because it’s good” (or, for that matter, any other “must”), clinicians could try considering the context. Ask “is this important to the client right now?”, “what effect am I hoping for and am I measuring it?”, “how can I guide the person to draw their own conclusions instead of telling them?”
In other words, attending to those contextual cues might just help us think of a bunch of alternative ways to help this person achieve their goals. And if we then ask the person to collaborate on HOW to reach those goals, suggesting the plans are experiments that both of you can evaluate. This helps reduce our human tendency to latch onto an idea, and then create a rule that isn’t always helpful.
Schmidt-Braekling, T., Waldstein, W., Akalin, E. et al. Arch Orthop Trauma Surg (2015) 135: 271. doi:10.1007/s00402-014-2146-x
Ververeli P, Lebby E, Tyler C, Fouad C. Evaluation of Reducing Postoperative Hip Precautions in Total Hip Replacement: A Randomized Prospective Study. ORTHOPEDICS. 1; 32: doi: 10.3928/01477447-20091020-09 [link]
Villatte, M., Viullatte, J., & Hayes, S. (2016). Mastering the clinical conversation: Language as intervention. The Guilford Press: New York. ISBN: 9781462523061