What it means to be a therapist


I wrote the following response to a discussion held recently on a Facebook group Exploring Pain Science – about the term “catastrophising”. It’s a term that elicits great anger and frustration from people living with persistent pain, and I see the term used poorly by clinicians as a judgement about another’s experience. There’s certainly plenty of research showing relationships between high levels of “thinking the worst” about pain, and poorer outcomes – but HOW we as clinicians respond to someone in distress may be more of a problem than the act of a person describing their fears and worries about the future. This is what I wrote:

I’ve been pondering – I think I see people as doing the absolute best they can to make the best decisions they can based on what they know at the time. And “knowing” means all the messy uncertainty, lack of logic, emotion and coercion from others! So whatever a person is doing to manage is the best they can do. All I can do is offer some options that I’ve seen other people use, maybe provide some more information, maybe even more accurate information, support people to be guided by what they see as important (usually values), and be there for them as they make their own minds up about what to do next. I’m a cheerleader, encyclopaedia, visualiser (lay out the options in a way that makes sense), perhaps a guide but only in so far as helping people notice things they hadn’t before.

To me, if someone is thinking the worst, it could be that they don’t have all the information about their resilience that they need, it might be misinformation about what’s happening in their body, it could be conclusions that over-estimate the threat and under-estimate resilience. It might also be difficulty pulling the mind away from sticky thoughts that stop clear thinking, or as one researcher called it “misdirected problem solving” – a way for the mind to remind the person that there’s an unresolved situation. It might also be feelings of helplessness, feeling like there is no point in trying anything new because nothing works anyway, a sense of not having enough energy to keep trying…

Those aren’t necessarily inaccurate thoughts, but they’re certainly not helpful thoughts, especially at 3.00am! So temporarily at least it seems helpful to bear witness to that person’s distress, to make room to be present, not to judge or dismiss but to allow those worst fears to be recognised. Sometimes bringing the worst fears out into the light shows that they can be managed better than expected, sometimes they fade into nothing, and sometimes they allow someone else to be there and support when the person’s run out of puff.

While I can understand how the language of uninvolved clinicians hurts because so often they fail to acknowledge the real distress of the person, I can still recognise that many of the contents of thoughts and beliefs won’t happen, – those scenarios are there wanting recognition, but they may not happen. If they do there will be things to do then – but mostly, when I catastrophise, I use it as energy to recognise how lacking I feel. And that’s not a nice place to be, but it’s simultaneously true (I lack) and untrue (others have what I need).

There’s a process I use for myself called creative catastrophising. I write down my worst fears, get them out on paper, make them visible. Sometimes that’s all I need to do. Other times I begin planning “what if X disaster happened, what would I do” – and when I’m in the right frame of mind, I can figure out a way to get by. I can’t tell anyone else to do that – but it’s a strategy that’s stood me in good stead as I’ve gone through the ups and downs of my life. It’s one way I cope.

Clinicians, if you can bear witness to another’s distress, without wanting to change, fix, judge or DO anything apart from being fully present, you’ll be doing the very best thing you can. The time for doing something “to help” is just around the corner – whatever you do, do NOT tell the person “you’re catastrophising” because this immediately means you’ve moved from being with to judging.

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5 comments

  1. Bronnie, I love your post because it incorporates all the important messages that we have tried to convey to clinicians in our recently published “reconsidered” definition of pain.

    Our definition specifically relates to the clinical engagement:

    https://journals.lww.com/painrpts/Fulltext/2018/04000/Reconsidering_the_International_Association_for.3.aspx

    The IASP has convened a special committee to report on the matter of whether or not its current definition needs to be modified or changed.

    1. Thank you so much John. I can understand where you’re coming from in terms of defining pain, but I think it comes unstuck because I’m describing how I respond, but I’m not describing the experience I’m responding to. To me the definition of pain should encompass a description of the “what it is to be experiencing pain” and should not incorporate “what people may do to respond to this experience in a clinical setting”. The experience of pain occurs when a person is alone, with others, feeling alone while in the presence of others, in the absence of a search for acknowledgement/cure/treatment, as well as in the presence of the same. Once we begin to extend the definition of pain to require the inclusion of another, we begin to move away from at least one part of the experience that seems to resonate with people – that while pain is being experienced, it is impossible to share or express, and that feeling the experience can be an extraordinarily isolating time. That’s been my situation and what I hear from others – does your definition require the experience to be witnessed by another for it to be “real”?

      1. We argue that the experience is one that is mutually recognisable in the clinical context. Does that answer your question?

      2. It’s the mutually recognisable aspect that bothers me the most. One of the things people often say to me is that they’re thought to be “just fine” when they’re feeling sore but not showing/talking about it. It’s very common to hear that patients are thought to be NOT experiencing pain by other clinicians, yet they report feeling a great deal of pain. Does this mean they don’t meet your definition of having pain?

      3. Bronnie, the answer to your question is – not at all!

        Let me quote from the relevant section of our paper:

        The above discussion emphasises how difficult it is to grasp an aporia. However, “pain” is clearly an experience only of a sentient being, one that can be recognised by others in the same species. So, we have characterised it as “mutually recognisable” to capture both the aporia and inherent intersubjectivity of pain, which are integral to a phenomenologically sound definition.

        Recognising mutuality in the proposed definition removes the element of doubt and the at times vexed and polarising issues of subjectivity and objectivity when a clinician is attempting to evaluate a patient’s experience. The term acknowledges the important point made in the Notes attached to the IASP definition: “each individual learns the application of the word through experiences related to injury in early life.”

        This helps to resolve the clinician’s dilemma, enabling a clinical encounter that ensures a mutual exploration of the patient’s beliefs, expectations, emotions, and perceived meanings of pain. This negotiated position stands to relieve the tension between the competing “privileges” of self-report and observer interpretation.

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