Off topic

…the “so what” question and why it matters to take a break from work

At the conclusion of each of the courses I teach at University of Otago, I ask students the “so what” question. So what that we learned about neurobiology? So what that we discussed social constructs and how they shape pain behaviour? So what that we learn that thoughts and beliefs influence our pain experience? What does it all mean when we’re sitting with a person experiencing pain?

This last week I’ve been on a brief trip to the West Coast of the South Island of New Zealand Aotearoa. It is a wild and isolated part of our country. So wild that in parts the annual rainfall is over 6,000mm (see the map below!), and the wind blows so that the trees grow almost horizontally. For two days there was no power (and thus no internet, no cellphone cover!) and the gravel road to our campsite was closed until 7.00pm while the power lines were being replaced… I won’t talk about the sandflies and mosquitoes – the size of helicopters!! Well perhaps I exaggerate…

Taking a break from talking pain brings me to my “so what” question. Why do I spend my time trying to help people, especially clinicians, learn about pain? Why am I so focused on bringing a narrative that says “we can’t reduce or remove all pain” and at the same time “it’s possible to live well with pain”? What is my “so what”?

Stepping back from the crabby discourse I see so often on social media – like whether hands on or hands off is preferable, whether pain is sensation or perception, whether exercise should be this or that – I think my purpose is to remind everyone, and especially clinicians, that when we’re working with someone who has weird pain that hangs around our job is to find out what this person’s main concern is. And to remember that irrespective of how much we help someone change their pain, ultimately, they will go on to live their own life. Not ours. Theirs.

It struck me from time to time as I swatted sandflies (helicopter sized ones, of course), that many of us work within inflexible processes and systems that demand we identify goals after only just meeting a person. It struck me that the people who develop policy and who get involved in establishing processes are not engaged in public discourse, at least, not in social media where so many of “us” hang out. I pondered how it is that the collective weight of allied health – numbering far more than our medical colleagues – has not yet shifted our conversations about best ways to help people with pain away from symptom reduction, despite our lack of success when it comes to pain. How we continually fixate on “if the pain goes, the person will go back to normal”. How we tout exercise as The Cure despite such small effect sizes on pain intensity, quality and disability. And for exercise, we could substitute needles, manual therapy, taping, medications…. How we want simple recipes, algorithms that sort people into “responders” and “non-responders” while failing to acknowledge that so far we haven’t achieved this and besides these approaches assume that everyone wants the same outcome.

Taking a break from work offers me a chance to refresh my perspective. My pain, it must be said, doesn’t take a break. And that, folks, is the reality for so many people in our communities. Because persistent pain persists. When we’re at work, and when we’re on holiday. When we’re trying to sleep, and when we’re busy with family. And we all come from what was our normal lifestyle. And some clinicians think that if only we would – understand pain neurobiology, pace, exercise, eat right, use mindfulness, check our thinking and get rid of maladaptive beliefs… then life would be fine. But would that life be what I want? Would it look like my life? Would I be able to be ME inside that regimen of all those things?

Clinicians, we can often omit to ask “what’s your main concern about your pain?” And we often forget to find out what that person values in their life. Our goal setting turns out to be OUR goals, often based on pain reduction – or focused on achieving X, Y, Z. Doing this means attention is paid to the end point – but then the process of getting there is left out. And life is a process (OK a journey) not a goal (OK a destination).

As I approach my teaching this year, and my interactions online, I want to emphasise respecting the autonomy and strengths people living with pain bring with them. That a person’s life and choices are theirs to make – and if we try to change people, we’ll fail. We can invite people to experiment with, play with, test, try out different ways of being, but unless we understand a person’s values and work with them, we’re probably not going get more than superficial compliance. Let’s be respectful and honour the complexity of each individual we encounter – and let’s not treat them as part of an algorithm.

A lot can happen in a week…

This time last week I had this mad idea to share some of my thoughts about “exercise” – not thinking that post would create such a stir! Is it really so radical to recognise that not everyone likes That Word? And that for some, the benefits of exercise aren’t as valued as other important parts of life? And that movements, like people, come in all shapes and sizes so what YOU like might not be something I like?

In New Zealand we’ve also had a new emergence of Covid19 in the community, after 102 days without any community-based cases. This has been very scary for some of us, a real frustration for others, and an economic blow for many others. It’s brought out the worst in our electioneering politicians (National, I’m looking at you), and in turn led to bad behaviour on the interwebs.

Bad behaviour, too, between clinicians on the interwebs. Behaviour unbecoming of senior white male clinicians, mainly. Not that this kind of unsocial behaviour is surprising to me: among some of our rehabilitation professionals there is a culture of “calling out” people who don’t hold similar beliefs, culminating in atrocious behaviour that serves no-one well. (ever heard of motivational interviewing and rolling with resistance?)

In case you hadn’t worked out, I’m a woman. Furthermore I’m a middle-aged woman – at the age where I suddenly become invisible. Those micro-aggressive behaviours of opening doors for me, lustful glances as I walk by, offers to buy me a drink… they’ve vanished. I’m like a piece of wallpaper. Because, as all women find, so much of my influence over the years has been based on my appearance.

Feminism has been part of my life since forever. I can’t recall when I first started resenting the ideologies that meant I wasn’t allowed to consider metalwork or wooodwork but had to study sewing and “home economics”. Or that I was advised I could be a nurse or a teacher, but never, despite having good marks in English, chemistry, biology, and physics (yeah I was that A-grade student) encouraged to consider a career in science or medicine.

These were overtly anti-female actions.

Then there have always been the slightly (but not always so minimal) “obligations” to watch how I dress, where I walk, how I sit, how I express an opinion (did you know I have a “strong personality”?!!). The time a senior male asked the two of us in an office “would one of you girls do this photocopying” – when both “girls” were over 50 years old?! Ask yourself who organises the coffee at your meetings – and who tidies up afterwards…

I look at the academics in my department: six women. Two are young and involved in the CREATE group, lab science developing bio-engineering solutions for cartilage degenerations. The other four have all had at least 15 years clinical career before completing a PhD, then maintaining that clinical career while also carrying out research. The men? Not so much.

When we begin to look at systematic disadvantages surrounding female participation in research, the strengths women bring into our applied clinical research programmes are often overlooked, particularly in career progression in academia. For example, we’re well-connected. We’ve had experience in clinical work so we can ask those awkward questions – and we often do. These questions are often complex because they’ve arisen from our daily clinical experiences. This means the questions lend themselves to mixed methods research, or intensive repeated measures research (single subject experimental designs, ecological momentary assessment designs), action research, qualitative methods. This kind of research doesn’t get published in Nature or Science.

And then we come to collaborations – where people meet in person (pre-Covid) it’s common to find women’s voices are not as loud, noticed or solicited. This practice begins at school (Wieselmann, 2019), and is evident most clearly in male-dominated work (Wright, 2016). While gender sensitivity training is available, it’s not possible to establish whether outcomes are improved, and many of these studies are about LGBT populations (Lindsay, Resai, Kolne & Osten, 2019). Intersectionality (where people are disadvantaged in many ways – eg sexual orientation, age, disability AND gender and ethnicity) means people in these groups are often stigmatised or invisible, excluded simply because they don’t fit with the established (ie male) norms. We have so much to do.

There have been superb examples of women researchers making themselves visible on social media. I’ve been fortunate to be included in some of these endeavours – raising my personal profile, but more importantly, helping me and others find each other!

My point in writing this post is that while many men are wonderful examples of compassionate, generous, kind and strong masculinity, there are others who are oblivious to their privilege. In their fear (although they would deny that they are afraid) they lash out at women who will not obey the rules this group of men cling to. We can call this fragility. A state where it’s perfectly fine to say that a defender of female under-representation is considered to have “allodynia of emotional pain”, arguing that “if you are this sensitive you might reconsider engaging in the Twitterverse.” Not only unprepared to acknowledge one woman’s response to his behaviour, but arguing for normalisation of this behaviour, along with exclusion for those who don’t agree.

I am calling for actively promoting the work of female commentators, researchers, clinicians and educators. Our voices are as valid as the currently dominating male ones.

I’m not calling for men like the one I’ve quoted above to be silent (though it’s hard to HEAR if you’re always doing the TALKING). I am calling for men who are recipients of privilege just by being male and because our society has held male norms as more valuable than female norms to be the change our societies need. Especially in healthcare where the attitudes I have seen demonstrated on Twitter suggest little sensitivity towards those with different experiences. I do wonder about the interactions with patients by those who have recently revealed their privilege and limited sensitivity on Twitter.

We can do better. Be positive and kind and compassionate and strong. We’ve got this, women.

Lindsay, S., Rezai, M., Kolne, K., & Osten, V. (2019). Outcomes of gender-sensitivity educational interventions for healthcare providers: A systematic review. Health Education Journal, 78(8), 958–976.

Wieselmann, Jeanna. (2019). Student Participation in Small Group, Integrated STEM Activities: An Investigation of Gender Differences. Retrieved from the University of Minnesota Digital Conservancy,

Wright, T. (2016) Women’s Experience of Workplace Interactions in Male‐Dominated Work: The Intersections of Gender, Sexuality and Occupational Group. Gender, Work and Organization, 23: 348– 362. doi: 10.1111/gwao.12074.

Mind your language!

“Words are pale shadows of forgotten names. As names have power, words have power. Words can light fires in the minds of men. Words can wring tears from the hardest hearts.”
― Patrick Rothfuss, The Name of the Wind

So much has been written about language, and I am not a linguist. I am, however, often accused of being pedantic because I like to use words with precision.

In the world of pain rehabilitation/management/treatment/care (see what I did there?!) certain words seem to spark a huge debate. Words like “pain”, “nociception”, “suffering”, “harm”, “avoidance”, “catastrophising” all get a regular hammering in online discussions. Less frequently, words like “guru”, “expert”, “master”, “authority”, “sage” reach the discussion boards and in the same way as “pain”, elicit an almost visceral response.

Before I begin commenting in earnest, I want to preface this piece by making it absolutely clear that I am not commenting on any particular person, organisation, group, business, or endeavour. Please read the whole piece thoroughly before commenting!

I’m not an expert, authority, sage, master or guru. I have years of experience and lots of learning, I’ve studied a lot, I’ve worked with lots of people living with pain, and I’ve worked across a wide range of settings – but they’re all in NZ. I work in an academic institution. I teach postgraduate pain and pain management from a certain perspective. I encourage my students and readers of this blog, as I do all the people I’ve tried to help, to always, always read and be critical of what I say.

I don’t know whether it’s part of growing up in the 1970’s, or it’s the religious upbringing I had, or whether it’s a New Zealand characteristic, but self promotion and the idea that I’m “more important” or more authoritative than anyone else is anathema to me. It’s probably why I give information away, and why I’m not a business owner.  Whatever the case I really dislike the idea of guruism. As a concept. As it is applied to healthcare.

When I think of the word guru, I think of someone who believes he or she knows more than normal people, someone who wants (or has) followers (disciples). It smacks of a lack of acknowledging that the more we know the more questions we have and the less we feel we actually know. The word puts the person on a pedestal.

Some people have been my gurus. People I’ve admired, wanted to emulate, who have influenced the way I think about things. I’ve put those people in a position of influence over me. I need to remind myself to be critical, to think independently, to hold different opinions if I’ve thought about the things they say. That’s not easy to do – highly charismatic people are great at influencing me, and in a field of practice where there is great uncertainty, it’s tempting to grasp what looks like an appealing concept and run with it. At this point I’m reminded of the quote: “For every problem there is an answer that is clear, simple, and wrong” (HL Mencken).

What strikes me is that guru is a term derived from Hindi (Sanskrit, actually) and according to Wikipedia and a few other etymology references, was a term accorded to “one who dispels the darkness and takes towards light, traditionally a reverential figure to the student, with the guru serving as a “counselor, who helps mold values, shares experiential knowledge as much as literal knowledge, an exemplar in life, an inspirational source and who helps in the spiritual evolution of a student.” (Thanks Wikipedia) Wikipedia goes on to say “the term is sometimes used in a derogatory way to refer to individuals who have allegedly exploited their followers’ naiveté.”

I see a couple of risks associated with identifying or being identified as a guru. The first is that we believe it ourselves. That we have the knowledge to “dispel the darkness”, and the right to “mould values… an exemplar, an inspirational source”. This can tempt us to be less aware of our own biases, to accept them or make exceptions for them. It can encourage us to think our view is “right”, to stop constantly asking ourselves those difficult questions.

The second is that our followers may do the same. Follow what we say without thinking independently. To read what we write without reading others. To forget to cross-check our work. Add to this the reality that most people who are adopted as gurus have years of experience and knowledge that underpins their superficially-simple (or should that be deceptively simple?) and readily digested approach. This experience and knowledge often can’t be replicated, or isn’t even explicit to adherents – so rather than a multi-layered and complex emergence of understanding, followers may simply pick and choose sound-bites, and apply them liberally and without the nuances the originator brought to the concept. Tell me you haven’t see this in pain rehabilitation over the years! And then, of course, comes the fighty talk and internet wars and tribalism we’ve seen so often.

The third problem or risk is that the people we try to help, those with pain, can be vulnerable to the hype. They too can believe that they “should” respond to the simple message, and if their own experience doesn’t accord with the “wisdom” of the guru, they can begin to blame themselves – and at times, be blamed by adherents.

There are undoubtedly other risks, but these are my key concerns about anyone being viewed as an expert or guru.

Every word begins with a few meanings within a certain context. Then the words grow a life of their own. Words are sociocultural – they have power despite “sticks and stones will break my bones but words with never harm me”. Words continue to acquire meaning and subtle use-changes over time. People in different parts of the world, of different backgrounds, at different ages and in different settings will use words quite differently. For me, guru is a word I really dislike, but for others it’s a legitimate term to describe themselves and their word. The thing is, whether we like it or not, the word has both good and not-so-good associations for people. And both matter. Guru might speak of “aha! here’s someone who can help”, or “a group I feel comfortable with – my tribe”, or “expert with lots of knowledge”. But it might also just as equally speak of hype, inflated ego, a need to be worshiped and collect adherents, blind allegiance.

Along with thinking hard about how I want to represent myself while writing this blog, I’ve also been pondering a list of various ways to describe pain and the neurobiological and experiential apparatus underpinning the experience.

Defining pain is incredibly difficult – while we’ve all experienced pain, we’ve never been able to share the “what it is like” to experience pain. Our personal experience of pain is within contexts we’re familiar with – for many people it really is a short-term experience, a warning of potential damage or threat to bodily integrity (and social, too), a symptom of “something else” that must be attended to, and something that will be resolved once that “something” is fixed. For others it is a stigmatising experience.

For some it’s an experience used to represent going through an ordeal and coming out the other side having learned something. For still others it’s a deeply scarring, personally disruptive experience that isolates and depresses and angers. For some it’s a mystery to be solved. For others it’s a neutral, uncomfortable yes but not distressing experience because it’s familiar and no longer understood to be representing anything much.

Most of these contextual experiences reflect appraisals of the ineffable experience, rather than distinguishing this experience from other experiences such as joy, hunger, fatigue. And I think it’s useful to remember the purpose of a definition – in the case of IASP pain definition, it has allowed researchers, clinicians, and people living with pain to acknowledge that nociception (and associated processes that contribute to our experience of pain) is not the same as pain. And that behaviours we do when we experience pain are also not pain. And that how we view or appraise our experience influences both the experience itself, and our response to it. And FWIW I use the term “it” as a placeholder for “the experience we know as pain”. 

Given that words are fluid, why on earth am I trying to argue the toss about how I view words like “guru” and “pain”? Because in this context, where people are talking with one another, clarity of meaning aids us to understand the concept we’re discussing. And because this is a particular context. And this is my opportunity to express my opinion. Readers will undoubtedly interpret what I’ve written in their own way. What I would ask is that people don’t interpret this post as having intentions I don’t have. After all, as the author, I’m probably the only person who can determine my intentions for what I write.

Heartjolts and gap-toothed smiles

Each time I hear a rumble-rattle-creak my heart jolts.  It might be the middle of the night, middle of the day or middle of my shower – these aftershocks are unpredictable and startling.  Yesterday’s 5.1 aftershock at 7:50 or so was a definite heartjolt – halfway through my shower!  With each one, that ‘living on the edge’ feeling comes back – do I need to drop, grab and hold?  Then ‘relax, breathe, calm’ as it passes.

Other heartjolts last longer.  Each time I drive past another building tilting on a crazy angle, with terrible cracks and fallen bricks.  Another red ‘condemned’ sign.  Demolition gangs in high-viz vests tearing away at the remaining skeletons of buildings that were hand-made, in an era when each wall was hand-crafted, each ornamental element had a function. Like rotting teeth, the stumps of our heritage appear between more modern constructions, waiting to be cleared away and refilled.

I’ve always had a sense of belonging in Christchurch.  I’m not native to the South Island, but an import from North Island.  Worse than that, I came direct from Auckland – not known to respect elder status in architecture.  Christchurch has had a profoundly peaceful and centering effect on my spirit.  It hasn’t the traffic plagues, nor the sprawl across the landscape that Auckland has.  It lacks height, with the exception of the Port Hills and, in the distance, the Southern Alps.  I used to get lost – no landmarks and a peculiar (to me anyway!) use of compass points to aid navigation. ‘If you go east, you’ll hit the sea, if you go west, you’ll hit the mountains’ I was told!  I preferred to use buildings as my anchors.

What I think I loved about Christchurch, and perhaps the aspect that caught my heart the most was a sense of respect for history.  I don’t mean the ‘first four ships’ history, but the way the elderly buildings had been retained and reused.  Take the Arts Centre – a gothic-style ex-university campus, vibrant and pulsing with artists living and creating within its grey stone walls.  The old stone church remodelled into a restaurant.  More recently the energising of back alleys and lanes into bars and clubs and specialty stores – even a brewery.  The humanising effect of brickwork, arches, facades and enormous timber beams on an otherwise concrete and glass environment.

Since Saturday my heart is heavy.  To see my heritage obliterated so quickly, so quickly.  Heartjolts each time I look at another gap.

At the same time – what is overwhelmingly clear is the transcendence of people.  He tangata.  It is people that live in this place, not buildings.  Buildings are artifacts.  While they represent parts of the people we are, they are not us.

And what gives my heart a real heartjolt is the collective resilience of people in my city.  First the workers who have, despite their personal challenges (homes lost, family distressed, even relocation for some) worked so hard to clear roads, restore power, water, sewage, check buildings for integrity, demolish buildings that are unsafe, document the events as they unfold and comfort people who are fearful.  Then the volunteers who have swooped and contributed muscle, sweat and brain to help those in most need.  And finally, those who have picked up the pieces of their ruined homes and, while still awed by the destructive power of Rauamoko, Maori god of the underworld, have been caring for family, friends and self.

What emerges from such shaking and turmoil is often a new sense of resilience.  If we can make it through this, we can make it through anything.  Kids seem to show us this first – time off school is for revelry and sport, great splits in the road are new playgrounds, sand volcanoes are for shovelling and moulding.  A gap-toothed smile from a 6 year old as she pushes her 4 year old brother around on his trike, both covered head to foot in silt and sand gives me a heartjolt.

Today as I look around the cityscape, I want to see those empty ruined spaces as a gap-toothed smile of a city becoming more in tune with people and the land in which we live.

Hutia te rito o te harakeke,
Kei whea te kōmako e kō?
Kī mai ki ahau;
He aha te mea nui o te Ao?
Māku e kī atu,
he tāngata, he tāngata, he tāngata

If the heart of the flax bush is removed, where will the bellbird sing?
If I am asked, what is the most important thing in the world;
I would reply,

It is people,

it is people,

it is people.

Briefly off topic

Look what I got up to over the weekend – is this ghoulish or what?!

Just look at how beautifully those bones fit together – strength, flexibility and interconnectedness. Poor ewe…

Bleached by the sun and wind, I’m not sure how this sheep died, but most of it was half-submerged in the sand, with only a few bones carried off by scavengers. The structures are incredible, fitting together with precision and beauty.
The last shot is taken on the Kaitorete Spit looking back towards the hills of Banks Peninsula.

The Virtual Revolution – BBC goodness

Don’t tell me you’re far too sophisticated to capitulate to silly pseudo-psychological tests – I know you do you, you know you want to!
So go ahead and enjoy this one from the BBC The Virtual Revolution and the Web Behaviour Test to find out which animal you are on the internet. I’m a hedgehog (prickly, slow but endearing!!)
…and yes, there is some science to it, and also yes, I’m changing the way I work on the computer as a result.