Psychology

Adam’s slow recovery


Not long ago I wrote about Adam Meakins back pain, and the astonishing response he’s had from fellow clinicians as he’s documented his recovery. Sadly, the polarised views of how therapists should approach a person with low back pain show me just how appallingly badly we adhere to low back pain guidelines… and worse, the kind of language and attitudes shown to a colleague who knows what he’s doing, demonstrates why change is so very slow.

What do I mean? Well, Adam has been following evidence-based low back pain guidelines that haven’t really changed a great deal since the advent of New Zealand’s “Yellow Flags” and guide to low back pain published waaaaay back in 1997. I’ve jumped to the NICE guidelines, as an example of one guideline, but you could look to many others.

NICE suggest these steps:

Assess for alternative diagnoses – in particular, “cancer, infection, trauma or inflammatory disease such as spondyloarthritis”

Risk assessment – basically, sorting people into those who are pretty OK with their pain, non-distressed and recommending those people receive “reassurance, advice to keep active and guidance on self-management.”

If Adam was distressed, or had a whole lot of risk factors for ongoing disability, then he might benefit from “more complex and intensive support for people with low back pain.” And yes, this mentions exercise programmes, manual therapy, psychological approaches.

Imaging – is not recommended, with imaging only used if the result is likely to change management.

Treatment – self-management, no orthotics or belts, no traction, and only offer manual therapy as part of an overall package that includes exercise.

No acupuncture, no electrotherapy.

Maybe use psychological therapies in conjunction with exercise.

Add in some NSAIDs

And don’t do much else…

In other words – exactly what Adam has been doing.

Why are there so many clinicians offering unsolicited opinions, without examining Adam, and without listening to his preferences, and without referring to the evidence?

What does this say about our clinical practice? What does it say about our confidence? What does it say about knowledge translation?

Most of all, what does this DO to the people we hope to help?

Seriously, folks. Watching the responses gives me nightmares.

I’ve been working in this field for 30 years now, and saying essentially the same thing about low back pain management for most of those years. I worry that an enormous business is built around scaring people, offering treatments with limited effect, for a condition that is common and responds well to doing normal movements.

In fact, one gripe I do have with the NICE guidelines is that they utterly and completely ignore daily life activities that a person needs to return to, and quickly. There’s nothing on managing sleep – and Adam’s described really rotten sleep until two days ago. There’s nothing on how to manage washing yourself, driving your car, sitting at a desk, doing the grocery shopping, preparing a meal, care for kids (or older parents) – absolutely nothing on the daily life activities that people need and want to do.

But, then again, I would say this – occupational therapists are the profession concerned about daily doing. The context of every day life. Knowledge translation from clinic/gym/exercise to what people actually do in their daily routines. It looks oh so simple – until you have to do it.

Back to Adam’s slow recovery. As I’ve watched Adam’s videos, I’m struck with the thought that many people just don’t know what to say – and so offer advice because that’s one way to deal with their own disquiet at helplessness. Clinicians, we need to develop better skills at managing our OWN emotional responses. We need to develop greater skills at sitting with our uncertainty. We need to stop leaping in with unsolicited advice that we offer just because we’re not comfortable doing nothing.

Could we just, for a moment, stop thinking about our reactions – and listen to what Adam (and I’m sure a whole bunch of our patients, too) says he wants? Listening means stopping that inner voice that’s got the “good” advice. It means really hearing what a person says. And only formulating a verbal response after we’ve digested the meaning the person is trying to convey.

Kia kaha Adam. You’re a brave man, a strong man, and I have much respect for you.

“Just a little scratch”


If you’ve had a blood test, flu jab or Covid-19 vax (please do, not just for you but for the vulnerable) you’ll probably have heard those words “Just a little scratch” then the needle goes in and ouch! I’ve wondered why phlebotomists and vaccinators use those words: is it to reduce the pain? give you some warning so you don’t pull away? why use the word “scratch” when it’s not a scratch?!

I suspect, though I haven’t read up on it, that the reason people say “just a little scratch” is to influence expectancies. Expectancies are defined as “cognitions regarding the probability of future experiences, events, and behaviour” (Peerdeman, van Laarhoven, Peters & Evers, 2016). In other words, what we expect to experience, happen or do influences what we actually experience, what happens, and what we do. Expectancies are really important when we consider placebo – and nocebo. Despite commentators who don’t consider placebo to be a thing (the response to being in a treatment ritual, over and above the effects of any active therapeutic agent), in pain, it is most definitely a thing, and one we need to be aware of as clinicians.

Back to expectancies.

Mostly, what we expect is what we experience. If we expect something to REALLY HURT then it’s likely to REALLY HURT! But what happens when we don’t expect something and it happens? Or when we expect something not to really hurt, but it actually does?

Peerdeman, Geers, Porta, Veldhuijzen and Kirsch (2021) investigated this mismatch between what we expect and what actually happens. It’s fascinating because the results weren’t quite in line with what the researchers thought…

What did they do?

The authors selected 82 healthy adults, aged between 18 and 30, with no health problems (physical or psychologist), no chronic pain, no current pain, no medications, no pacemakers, and no pregnancy. The participants weren’t allowed to use any medication, alcohol or other drugs in the 24 hours before the experiment.

Two experimenters undertook the experiments – one wasn’t aware of who was getting what, while the other was unaware of what was getting what until just before she gave the verbal suggestion. The experimenter who was blinded left the room before the second one gave the suggestion, in order to remain blinded throughout.

The participants were wired up to record heart rate, skin conductance, and then thermal and nociceptive perception thresholds were identified – at least in part to give participants a chance to get used to the heat stimulus. The experimenters went in to increase the heat to identify the temperature where participants indicated the pain was “moderately high” (who volunteers for these experiments? Oh – they recruited from around the university and on social media...). Then the experimenters got to work: participants were randomised to get either a suggestion of “no pain” (they’d already had three occasions where the thermal stimulus wasn’t painful, and three where it was), or a suggestion of moderately high pain. Then the stimulus was applied four times, with participants having to rate the expected pain intensity, how certain they were of this prediction, and how afraid they were. Afterwards, they were asked to rate pain intensity and unpleasantness.

For all the details of this experiment, head to the paper itself – it’s very detailed, and could be replicated.

Results

One person dropped out before the trial began – it was too painful – leaving 81 people remaining. The average age was 22 years, but the investigators don’t report gender.

When people were told “it’s not going to hurt” participants rated the pain lower than those who were told it was going to hurt, and while the ratings changed depending on what they experienced, when it was again suggested they’d feel no pain – again their pain ratings were lower than expected. Who knew pain intensity could vary so much? Reported pain intensity in the people who were told they wouldn’t experience pain was 4/10 points lower than the other group who were told it would hurt, and a bit over 2 points lower the second time (on a 0 – 10 numeric rating scale). That’s a thumping great amount of pain reduction! Add to this, these participants also were less afraid of their pain than the other group.

BUT, and this is important, participants in the “it’s not going to hurt” group reported less trust in the experimenter (who would have thought, huh?!). So beware: if you tell someone “oh this won’t hurt a bit” – they may experience less pain, but they’ll look at you sideways and be a bit wary of you because you violated their trust.

Discussion

I haven’t described the second experiment because of space, but go ahead and read it. Essentially they added some more participants, varied the procedure a little to reduce the memory burden on participants, and added a “medium” underprediction element into the process. The results showed similar outcomes – lower ratings of pain in both the “you won’t feel a thing” and the “it’ll hurt but not much” experiments, and yet again, less trust in the experimenter suggesting that it wouldn’t hurt.

Lessons to learn?

Think carefully about inflating how much pain relief someone will experience, especially if you’re going to see that person again. While people might experience less pain, losing someone’s trust in a therapeutic setting is a serious problem. The authors point out that healthy volunteers in a lab setting, getting short-term pain, is not like a therapeutic setting where it’s probable that trust is well-established. We don’t know what effect violating trust in a longer-term relationship might have.

At the same time – it does strike me as intriguing that simply being told “it won’t hurt” can influence pain intensity rating. What’s going on? How can a communication stimulus influence an experience? How could a psychological input change the way we perceive a noxious stimulus? Perhaps the way forward might be to use neutral language or, more positively, suggest that the person can handle it? “Just a little sting and you’ll get through”

Peerdeman, K. J., Geers, A. L., Della Porta, D., Veldhuijzen, D. S., & Kirsch, I. (2021, Jul 1). Underpredicting pain: an experimental investigation into the benefits and risks. Pain, 162(7), 2024-2035. https://doi.org/10.1097/j.pain.0000000000002199

Peerdeman KJ, van Laarhoven AI, Peters ML, Evers AW. An Integrative Review of the Influence of Expectancies on Pain. Front Psychol. 2016;7:1270. Published 2016 Aug 23. doi:10.3389/fpsyg.2016.01270

Why I don’t trust my clinical reasoning: and why this matters


“See someone experienced” I hear people with pain say. “They’ll know what’s wrong with you.”

Well, based on the research I’ve read, I wouldn’t be so sure. In fact, I’m certain my own clinical reasoning is biased, prone to errors that I don’t notice, and influenced by factors that most clinicians would be horrified to think they, too, were influenced by.

Let me give you a few to ponder:

I’m interested in women and pain – and there’s a lot of evidence showing that women’s pain doesn’t get the same kind of diagnostic and management attention as men. Now part of this is due to the inherent bias in research where experimental studies often rely on male rats, mice and undergraduates because they don’t have those pesky hormonal fluctuations each month. Even volunteering to take part in a pain study has been found to be biased – people who volunteer have been shown to be more risk-taking and more extraverted (Skinner, 1982) – though to be fair this is an old study!

But contextual factors such as gender, distress and even the supposed diagnosis do influence judgements about pain intensity (Bernardes & Lima, 2011) including potentially life-threatening chest pain (Keogh, Hamid, Hamid & Ellery, 2004). Gender bias has been identified in a large literature review of gender bias in healthcare and gendered norms towards people with chronic pain (Samulowitz, Gremyr, Eriksson & Hensing, 2018).

And if you have the misfortune to be judged to have low trustworthiness and you’re a woman, you’re more likely to be thought to have less pain and to be exaggerating your pain (Schafer, Prkachin, Kaseweter & Williams, 2016). Beware if you’re overweight and a woman because you’ll be likely judged as having less intense pain, the pain will be judged as less interfering, more exaggerated and less related to “medical” factors – women’s pain in particular is likely to be judged as “psychological” and given psychological therapy rather than other treatments (Miller, Allison, Trost, De Ruddere, Wheelis, Goubert & Hirsch, 2018).

The weird thing is that the clinicians involved in these studies were oblivious to their bias. And let’s not even go there with people of colour or so-called “minority” groups such as LGBTQI.

So as clinicians our initial impressions of a person can lead us astray – and I haven’t even started with the contribution experience has on clinical reasoning. Let me go there then!

Something that cognitive psychologists have explored for some years now, is the type of thinking that we draw on for clinical reasoning. System one is “fast reasoning” – where we rapidly, instinctively and emotionally make decisions on the fly. Kahneman (1982) first described these two processes and noted that fast thinking gets better with rehearsal and are helpful especially for skilled clinicians needing to make decisions in pressured contexts, and draw on “pattern recognition” – or to be precise, draw on deviation from a recognised pattern (Preisz, 2019). System two is “slow reasoning” where decisions are made in a considered way, are not influenced by emotional state, and can be thought of as “rational.” Slow thinking is most useful where the situation is complex, where decisions need to weigh multiple pieces of information, where the situation might be novel, or where, for persistent pain in particular, there are multiple disease processes occurring.

OK, so we should choose system two, right? Not so fast! System one is hard to switch from – it’s what underpins “intuition” or “hunches” – and it gets more entrenched the more experienced we are. According to Preisz (2019), system one “seeks to form a coherent, plausible story by relying on association, memories, pattern matching and assumption.”

Why is system one thinking not so great? Well, we’re human. We’re human in the way we respond to any reasoning situation – we anchor on the first and most “plausible” ideas, and these might be unrelated to the actual presentation we see. For example, if we’ve been reading a journal article on a new treatment and its indications, it’s amazing how many people will present with those exact same indications in the next week! This is availability bias or anchoring bias. We’re also inclined to believe our own patients and judgements are different from “those people” – especially “those people” who might respond best to clinical guidelines. This means that even in the face of clear-cut research showing the lack of effects of knee arthroscopy (Brignardello-Petersen, Guyatt, Buchbinder, Poolman et al, 2017) an orthopaedic surgeon I know argued that “we choose our patients very carefully” – essentially arguing that his patients are different, and this approach is the best one.

If experienced clinicians find it hard to “unstick” from old practice, or move quickly to “intuitive” reasoning (even if it’s called “pattern recognition”), and if we all find it hard to recognise when we’re biased, or even that we are biased, what on earth should we do? All us old hands should retire maybe? All follow algorithms and not use “clinical judgement”? Take the “human” out of clinical management and use AI?

Some of these things might work. There is evidence that algorithms and AI can offer effective and (perhaps) less biased diagnosis and management than our unaided human brain (Kadhim, 2018) but there are also studies showing that direct comparisons between decision aids and clinical judgement are rarely made, and those that have been carried out don’t show superior results (Schriger, Elder, & Cooper, 2017). But watch this space: AI is a rapidly developing area and I predict greater use of this over time.

The risk with decision aids is – garbage in, garbage out. If we look at existing research we can see that male, pale and potentially stale dominates: this doesn’t bode well for people of colour, for women, for the unique and idiosyncratic combination of diseases a person can have, or for untangling the impact of disease on the person – in other words, disability and illness.

So, to summarise. We are all biased, and it’s best to acknowledge this to ourselves upfront and personal. We can then turn to strategies that may reduce the biases. For me, the one I turn to most often is a case formulation, using information gathered from a semi-structured interview and a standard set of questionnaires. These have been developed a priori so my biases in information gathering are limited. By taking time to follow a case formulation, my thinking is slowed to that more deliberative system two. At least some of the biases I know I’m prone to are mitigated.

And yet, I know I am biased. That’s why I use a supervision relationship to help me identify those biases, to be challenged and to reflect.

Bernardes, S. F., & Lima, M. L. (2011, Dec). A contextual approach on sex-related biases in pain judgements: The moderator effects of evidence of pathology and patients’ distress cues on nurses’ judgements of chronic low-back pain. Psychology & Health, 26(12), 1642-1658.

Brignardello-Petersen, R., Guyatt, G. H., Buchbinder, R., Poolman, R. W., Schandelmaier, S., Chang, Y., Sadeghirad, B., Evaniew, N., & Vandvik, P. O. (2017, May 11). Knee arthroscopy versus conservative management in patients with degenerative knee disease: a systematic review. BMJ Open, 7(5), e016114. https://doi.org/10.1136/bmjopen-2017-016114

Kadhim, M. A. (2018). FNDSB: A fuzzy-neuro decision support system for back pain diagnosis. Cognitive Systems Research, 52, 691-700. https://doi.org/10.1016/j.cogsys.2018.08.021

Kahneman, D., Slovic, S. P., Slovic, P., & Tversky, A. (1982). Judgment under uncertainty: Heuristics and biases. Cambridge university press.

Keogh, E., Hamid, R., Hamid, S., & Ellery, D. (2004). Investigating the effect of anxiety sensitivity, gender and negative interpretative bias on the perception of chest pain. Pain, 111(1-2), 209-217.

Miller, M. M., Allison, A., Trost, Z., De Ruddere, L., Wheelis, T., Goubert, L., & Hirsh, A. T. (2018, Jan). Differential Effect of Patient Weight on Pain-Related Judgements About Male and Female Chronic Low Back Pain Patients. J Pain, 19(1), 57-66. https://doi.org/10.1016/j.jpain.2017.09.001

Preisz, A. (2019, Jun). Fast and slow thinking; and the problem of conflating clinical reasoning and ethical deliberation in acute decision-making. Journal of Paediatric Child Health, 55(6), 621-624. https://doi.org/10.1111/jpc.14447

Samulowitz, A., Gremyr, I., Eriksson, E., & Hensing, G. (2018). “Brave Men” and “Emotional Women”: A Theory-Guided Literature Review on Gender Bias in Health Care and Gendered Norms towards Patients with Chronic Pain. Pain Research and Management, 2018.

Schafer, G., Prkachin, K. M., Kaseweter, K. A., & Williams, A. C. (2016, Aug). Health care providers’ judgments in chronic pain: the influence of gender and trustworthiness. Pain, 157(8), 1618-1625. https://doi.org/10.1097/j.pain.0000000000000536

Schriger, D. L., Elder, J. W., & Cooper, R. J. (2017, Sep). Structured Clinical Decision Aids Are Seldom Compared With Subjective Physician Judgment, and Are Seldom Superior. Ann Emerg Med, 70(3), 338-344 e333. https://doi.org/10.1016/j.annemergmed.2016.12.004

Skinner, N. F. (1982, 1982/12/01). Personality characteristics of volunteers for painful experiments. Bulletin of the Psychonomic Society, 20(6), 299-300. https://doi.org/10.3758/BF03330107

“Intuition” – and clinical reasoning


Intuition is one of two main modes of thinking, according to Daniel Kahneman. Intuition is fast, considers the whole rather than components of the whole, and intuition feels effortless. Intuition can also be wrong – but often isn’t (Gruppen, Woolliscroft & Wolf, 1988).

We use intuition well when we’ve been exposed to many examples of the phenomenon under consideration – for example, if we’ve seen a lot of patients with similar health problems. We don’t use intuition well when we buy into biases or stereotypes.

The alternative to intuition is slower thinking, that typically breaks the considerations into smaller pieces, often following a linear process where data (information) is collected and assembled. This kind of thinking is reasonably easy to investigate, whereas intuition is much more difficult to study (it’s fast, people can’t describe how they arrived at a conclusion, so it’s not amenable to self-report).

Why worry about it? Well, intuition is the key strategy described by allied health, particularly physiotherapists, when considering whether a person needs further assessment for those pesky psychosocial factors (Man, Kumar, Jones & Edwards, 2019). What this means in practical terms is that a patient who doesn’t fit the stereotypical “risky yellow flags patient” may have to fail at conventional treatment before being directed towards a multidisciplinary, or biopsychosocial, approach.

What might be an alternative?

I’m pretty fortunate in that I work in a service where participants to my group programme have already completed a series of questionnaires as a requirement to participate in pain rehabilitation and management. So everyone I see will have some information I can draw on without my needing to add anything more. Of course, I can argue that some of the questionnaires don’t help me very much because they’re fairly biased towards a CBT model of chronic pain management. But the principle is pretty clear: everyone gets to complete the questionnaires ahead of time.

Practically, this isn’t always easy. Many people don’t have good literacy skills, don’t have a computer, hate the thought of paperwork (even in electronic form), and some of the questions don’t work very well/aren’t relevant to the people I see, so they choose not to fill them in. There’s no opportunity to discuss the responses with a clinician, so it’s not easy to decide whether the questions apply.

But what happens when we leave the questionnaires to luck, intuition or “the psychologist”?

Firstly, we know the relevance of psychosocial risk factors. We know this so well – it’s been a theme throughout the years I’ve worked as a clinician in pain rehabilitation and management. If we don’t include these in our formulation (treatment planning), we’re probably not including them as key predictors for outcomes…

We can’t rely on our intuition because for many of us, those people who do have risk factors will only overtly show these once they’ve failed to progress – it’s at that time they’re more distressed, frustrated and afraid, so behavioural markers for psychosocial risk factors are more evident. This also means someone will have to work with the person who is now more distressed than they needed to be.

We don’t use our team to best advantage. Why refer someone to an occupational therapist, to a psychologist, to a counsellor if we don’t know why the person needs to see them? This can lead to a distinct lack of briefing or information about the referral to the person with pain – and sometimes, it seems, to the person deciding they don’t need, or want, that referral even when it would be in their best interests.

Mostly, though, I think it begins to bias our thinking. We can become judgemental – why doesn’t this person do their home-based exercise programme? Why are they just going through the motions? Why do they keep on complaining about their pain? We can begin to question the person’s motivation, their lifestyle, the validity of their perspective.

The real problem?

Our clinical reasoning models don’t help us very much when it comes to synthesising psychosocial factors. When we’re dealing with those factors using “intuition” we don’t have to incorporate them into our models – because intuition isn’t explicit, it’s quick and difficult to articulate. To date there are very few transprofessional models of pain management, and even fewer that attempt to link theoretical constructs with what we see in front of us. That synthesis of biological, social and psychological constructs that uniquely explains why this person is presenting in this way at this time, and what factors may be maintaining this person’s predicament. It’s no wonder that, in a recent study my colleagues and I have been conducting, we’ve found very few clinicians collaborating on a case formulation.

My suspicion is that until we develop a collaborative case formulation clinical reasoning approach that can integrate these many factors in a sensible and logical way, our “intuition” is likely to leave us floundering. The casualties of this particular mess are the people we hope to treat. I wonder if it’s time to work together, physiotherapists, occupational therapists, psychologists and medical practitioners (and all other variants of health practitioner!). Do we need to create a synthesis that works as a transprofessional model of pain?

Gruppen LD, Woolliscroft JO, Wolf FM. The contribution of different components of the clinical encounter in generating and eliminating diagnostic hypotheses. In research in medical education: proceedings of the annual conference. Med Educ. 1988;27:242‐247.

Man, Isabella, Kumar, Saravana, Jones, Mark, & Edwards, Ian. (2019). An exploration of psychosocial practice within private practice musculoskeletal physiotherapy: A cross-sectional survey. Musculoskeletal Science and Practice, 43, 58-63. doi: https://doi.org/10.1016/j.msksp.2019.06.004

Widerström, Birgitta, Rasmussen-Barr, Eva, & Boström, Carina. (2019). Aspects influencing clinical reasoning and decision-making when matching treatment to patients with low back pain in primary healthcare. Musculoskeletal Science and Practice, 41, 6-14. doi: https://doi.org/10.1016/j.msksp.2019.02.003

Three letter acronyms and what they mean – CBT, DBT, CFT, ACT – not alphabet soup!


Once you begin to dip your toes into psychological therapies, it doesn’t take long before you begin to see TLAs all over the place. So today I’m going to post on two things: some of the TLAs, and why or how we might consider using these approaches in pain rehabilitation.

The first one is CBT, or cognitive behavioural therapy. CBT grew out of two movements: behaviour therapy (Skinner and the pigeons, rats and all that behaviour modification stuff), and cognitive therapy (Ellis and Beck and the “cognitive triad” – more on this later). When the two approaches to therapy are combined, we have cognitive behavioural therapy where thoughts and their effect on emotions and actions are the focus of therapy, with a secondary focus on behaviour and how behaviour can be influenced by (and influence) thoughts and emotions.

In pain rehabilitation, cognitive behavioural therapy is used primarily by psychologists, while a cognitive behavioural approach is what underpins most of the multidisciplinary/interprofessional pain management programmes. These programmes were very popular and effective during the 1980’s and 1990’s, but have faded over time as insurers in the USA in particular, decided they were expensive and should instead be replaced by what I call “serial monotherapy” – that is, treatments that were provided in a synthesised way within interprofessional programmes are often now delivered alongside or parallel to one another, and typically with very limited synthesis (or case formulation). A question yet to be answered is what effect this change has had on outcomes – my current understanding is that the outcomes are weakened, and that this approach has turned out to be more expensive over time because each discipline involved is seeking outcomes that fit with their priorities, and there is far more opportunity for duplication and gaps in what is provided.

Cognitive behavioural approaches underpin the “Explain Pain” or pain neurobiology education approach. The theory is that people who hold unhelpful beliefs about their pain can become fearful of what the pain means. Once they hold more helpful or realistic beliefs about their pain, that emotional zing is reduced, and it’s less scary to begin moving.

Cognitive behavioural approaches also underpin cognitive functional therapy. In cognitive functional therapy, as a person begins to move, the therapist asks about what’s going through their mind, and establishes through both movement experiments and information, that they’re safe to move, and can do so without fear (O’Sullivan, Caneiro, O’Keeffe, Smith, Dankaerts, Fersum & O’Sullivan, 2018).

When carrying out graded exposure, in the way that Vlaeyen et al describe, a cognitive behavioural approach is integral. In this approach, the classic relationship between avoidance and a stimulus (bending forward, for example), is challenged in a series of behavioural experiments, beginning with movements the person fears the least, and progressing over time to those the person fears the most.

There’s good evidence from psychological therapies, and also from within pain rehabilitation research, that it’s the behavioural aspects of therapy that do the heavy lifting in pain rehabilitation (Schemer, Vlaeyen, Doerr, Skoluda, Nater, Rief & Glombiewski, 2018).

And, in the words of Wilbert Fordyce, psychologist who first started using a behavioural approach for persistent pain management “Information is to behaviour change as spaghetti is to a brick”.

So don’t expect disability (which involves changing behaviour) to shift too much without also including some strategies for helping someone DO something differently. And if a person doesn’t accept what you’re telling them – sometimes it’s more effective to try helping them do things differently first, and use that experiential process rather than talk, talk, talking.

ACT (acceptance and commitment therapy), and DBT (dialectical behaviour therapy) are both what is known as “third wave” cognitive behavioural therapies. They both involve understanding the relationship between thoughts, emotions and behaviours, but add their own flavours to this. In the case of ACT, the flavour that’s added is “workability” and contextual behavioural analysis, with relational frame theory as the underpinning theoretical model. Instead of directly tackling the content of thoughts, ACT focuses on changing the relationship we have with thoughts, and shifts towards using values as directing the qualities of what we do (McCracken & Vowles, 2014). Dialectical behavioural therapy helps people build social relationships that support them, begin to recognise strengths and positive qualities about themselves, recognise unhelpful beliefs about themselves and shift towards more helpful beliefs, and to use coping strategies to help soothe and calm emotional responses. I draw on ACT as my primary framework for pain rehabilitation (actually for my own life too!), but I haven’t seen as much use of DBT in this area.

Compassion focused therapy, the other CFT, is also a psychotherapy designed to help people become compassionate towards themselves and others. The theory behind this are understanding three main “drives”: the threat and self-protection system, the drive and excitement system, and the contentment and social safeness system. When these are under-developed, or out of balance, unhelpful behaviours and unhappiness occur. CFT aims to help people bring the three systems into balance. Given that many of the people who experience persistent pain have also experienced early childhood trauma, and concurrently endure stigma and punitive responses from those around them because of their pain, CFT offers some strategies to help effect change on an unsettled and fearful system. CFT uses self appreciation, gratitude, savouring, as well as mindfulness (non-judgemental awareness), and compassion-focused imagery to help soothe the system (Penlington, 2019; Purdie & Morley, 2016).

Along with these TLAs, you can also find many others. I think for each approach, understanding the theory behind them is crucial. While some of these approaches appear very “psychological”, whenever we begin unpacking them, we can start to see how most of what we offer in physical or occupational therapeutic approaches require us to draw on them.

Skills like guided discovery, motivational interviewing, goal-setting, values clarification, graded activity, helping people experience difference in their own lives, soothe their own body, become more comfortable with a sense of self that has to grapple with pain – unless we’re knocking our patients unconscious, we’re going to be using these so-called “psychological” skills.

If we are doing good therapy, I think we need to be as excellent as we can in all the skills required. This includes being excellent at the way we thoughtfully and mindfully use communication.

Psychological therapies all incorporate communication, and responses to people who are fearful of something. Most of us are involved in helping people who are afraid of their pain – and as a result are not doing what matters to them. If we don’t help people do what’s important in their lives, what on earth ARE we doing? For this reason, we need to employ the most effective tools (ie psychological approaches) in just the same way we use goal-setting (psychological), respond with encouragement to someone attempting a new thing (psychological), start with something the person can only just do, then grade it up (psychological), help down-regulate an overly twitchy nervous system (psychological), teach new skills (uh, that’s quite right, psychological!). I could go on.

What don’t we do if we’re using psychological strategies? We don’t dig into deep trauma, substance abuse, criminal behaviour, self harm, psychopathology. Though, we do address some psychopathology if we recognise that depression and anxiety both respond quite nicely to scheduling positive activities, and meaningful movement (ie exercise). Perhaps our artificial divide between “physical” and “mental” needs to be altered?

McCracken, L. M., & Vowles, K. E. (2014). Acceptance and commitment therapy and mindfulness for chronic pain: Model, process, and progress. American Psychologist, 69(2), 178.

O’Sullivan, P. B., Caneiro, J. P., O’Keeffe, M., Smith, A., Dankaerts, W., Fersum, K., & O’Sullivan, K. (2018). Cognitive functional therapy: an integrated behavioral approach for the targeted management of disabling low back pain. Physical therapy, 98(5), 408-423.

Penlington, C. (2019). Exploring a compassion-focused intervention for persistent pain in a group setting. British journal of pain, 13(1), 59-66.

Purdie, F., & Morley, S. (2016). Compassion and chronic pain. Pain, 157(12), 2625-2627.

Schemer, Lea, Vlaeyen, Johan W., Doerr, Johanna M., Skoluda, Nadine, Nater, Urs M., Rief, Winfried, & Glombiewski, Julia A. (2018). Treatment processes during exposure and cognitive-behavioral therapy for chronic back pain: A single-case experimental design with multiple baselines. Behaviour Research and Therapy, 108, 58-67.

Toye, F., & Barker, K. (2010). ‘Could I be imagining this?’–the dialectic struggles of people with persistent unexplained back pain. Disability and rehabilitation, 32(21), 1722-1732.

Veehof, M. M., Trompetter, H. R., Bohlmeijer, E. T., & Schreurs, K. M. G. (2016). Acceptance-and mindfulness-based interventions for the treatment of chronic pain: a meta-analytic review. Cognitive behaviour therapy, 45(1), 5-31.

Clinical reasoning models: what’s wrong with them?


I’ve been interested in clinical reasoning and models used in clinical reasoning for quite some time. Occupational therapy has several models, including the “occupational therapy problem solving process” by Lela Llorens, the Model of Human Occupation by Gary Kielhofner, and the Canadian Model of Occupational Performance by Polatajko, Townsend and Craik in 2007. All of these models were designed to support occupational therapy clinical reasoning processes, and to capture the essence of what occupational therapy is about.

When it comes to pain rehabilitation, I’ve found the occupational therapy models a little lacking in specificity for my clinical reasoning. I’ve also noticed similar problems with proposed clinical reasoning models for physiotherapy when considering pain.

Here’s the thing: if pain involves so many factors (call them biopsychosocial for want of a better all-encompassing term), and we don’t know which factors are relevant for this person at this time, clinical reasoning in pain rehabilitation is complex. Why? Well the problem with pain is that it’s full of ambiguity. Not so much for the person experiencing them, but certainly for the clinician trying to help.

Bear with me a minute. To me, clinical reasoning models help shape the factors we include and those we omit.

In writing that sentence I realise I’m assuming something crucial: that models are designed to help us predict and control what’s going on. Is that the purpose of a model? I quickly did a search and found this definition: “In science, a model is a representation of an idea, an object or even a process or a system that is used to describe and explain phenomena that cannot be experienced directly. Models are central to what scientists do, both in their research as well as when communicating their explanations… Models are a mentally visual way of linking theory with experiment, and they guide research by being simplified representations of an imagined reality that enable predictions to be developed and tested by experiment.” It’s from here.

OK, so in clinical reasoning what utility does a model need? I think a model needs to generate hypotheses that explain the unique presentation of this person, their problems, at this time. A nomothetic representation of what might be going on for this unique person.

Occupational therapists and physiotherapists, and probably psychologists, are all concerned less about impairment (that’s damage or dysfunction at the body structure level) than we are about the impact this has on functional limitations and on participation. This doesn’t mean we’re not interested in impairment, but our focus is much more likely to be on “and what impact does that have on what you need and want to do”. Occupational therapists, in particular, are concerned about “and how does this affect the way you participate in our world”.

But if we look at clinical reasoning models in our various professions I think there are some gaps. I don’t think our models invite us to generate hypotheses because the various clusters of information don’t seem to link together in a terribly coherent way. Yet – with all the information around us, there are some causal (or bidirectional) relationships we can consider.

For example, we know that if someone is very fearful of their pain, they’re likely to describe elevated physiological arousal, and they’re not as inclined to engage in movements they believe will exacerbate their pain.

A line of reasoning goes from Fear -> Physiological arousal and Fear -> Avoidance.

This simple set of hypotheses generates some ideas about what might help. Firstly we’d test the presence of fear – is it just happening in this moment, or is it something that’s been present consistently? Mostly we ask the person, but we could use a questionnaire measure of fear of pain. We could also test for physiological arousal – is this present? How do we know? We could use various biofeedback devices, or we could simply ask (or use a questionnaire). And of course we can test for fear-avoidance as a combined construct via questionnaire and/or behavioural testing.

This set of steps really just determines whether our hypotheses are present, so now we need to generate some treatments. In this case, we also draw on research and think about providing information – this, we hypothesise, should reduce reported fear. So we embark on some explanations about what’s going on – and we should see a reduction of fear on a measure of pain-related fear. But perhaps not on avoidance because we know that behaviour change requires more than simply information. We might also help the person down-regulate their excitable nervous system, reducing that “fear -> arousal” relationship. And finally we might begin doing some exposure work which acts on reducing fear in the presence of doing something scary (movements) and so reduce the relationship between fear -> avoidance.

What the example above shows us is what might happen once we’ve identified some potential phenomena that may be present. What it doesn’t show, and something I struggle to find in many clinical reasoning models, is how clinicians identify those phenomena. Why would someone think to ask about fear of pain? Especially if we believe that our job is to help reduce pain and pain’s the only reason the person isn’t doing things. And even more – if we think our job is to deal with “physical” and fail to recognise the relationship between “physical” and “feelings, beliefs”.

You see, I think broad “groups of factors to consider” belongs in the assessment, but we need something more tangible when formulating an individualised explanation. We need to be generating hypotheses about how these various factors interact and lead to a presentation – and while much of this will be conjecture initially, by generating various hypotheses we can then go on to test them – and ultimately establish the priorities for treatment in collaboration with the person. That’s much easier to do when we’ve fleshed out why the person isn’t able to do what’s important to them, and we’ve synthesised all the known factors in some explanatory model.

Is this complex? Yes – but who said it had to be easy? This is why we do the work we do, because it’s complex and “common sense” doesn’t cut it. And if our various professions really want to adopt a sociopsychobiological framework for pain, maybe our clinical reasoning models need to synthesise all these factors in some coherent way rather than simply plonking the groups of factors down without integrating what’s known about the relationships between variables from different domains.

Wacker, J. G. (1998). A definition of theory: research guidelines for different theory-building research methods in operations management. Journal of Operations Management, 16(4), 361-385.

Yazdani, S., Hosseinzadeh, M., & Hosseini, F. (2017). Models of clinical reasoning with a focus on general practice: A critical review. Journal of advances in medical education & professionalism, 5(4), 177-184.

Clinical reasoning & meaning-making (a long post)


Clinical reasoning is a cornerstone of evidence-based healthcare, in fact some would argue it’s the cornerstone of all healthcare. While there are many different processes, the ultimate purpose of clinical reasoning is to ensure the person seeking help has their needs identified then met, and the clinician has a basis upon which to decide which treatment they should offer.

The approach we use in clinical reasoning, including the information we prioritise and search for, and the way we synthesise the information to make sense of it will depend on the model we have to explain our treatment approach. For example, if we’re occupational therapists, we’re looking for information about the occupations the person wants and needs to do (identifying the person’s needs), and we search for information to help explain how and why this person is unable to manage their occupations at this time. Because occupational therapy is concerned with context – social, interpersonal and environmental, as well as looking at pathophysiological processes, we will also review psychosocial-spiritual factors (beliefs, attitudes, desires, interactions, values, etc) and the physical and social environment/s as part of our clinical reasoning.

Meaning making

But… there’s something missing from this picture of how we go about doing clinical reasoning: the very process of enquiring about “daily doing” (aka occupation) is likely to influence the person seeking help. There is a dynamic process involved in making sense of what’s going on between the clinician and the person. Some would call this “intersubjectivity” (Quintner & Cohen, 2016) meaning “a shared perception of reality between embodied agents… meanings expressed through performance and …perceived by others”, some would call it “embodiment” (Arntzen, 2018) meaning bodily aspects of human subjectivity and referring to my phenomenological body (the way I experience my body), and still others wouldn’t recognise it at all! I like to call it “meaning making” or the way that both parties make sense of what goes on in the “meet the therapist moment” as Benedetti (2011) puts it.

Much of the discussion about clinical reasoning refers to the way clinicians blend implicit/tacit knowledge (knowledge that’s so well-learned that it’s hard to state exactly what it is) with explicit/declarative knowledge (knowledge that we can articulate). Each profession has its own implicit body of knowledge that frames the way they approach the clinical problem. I think patients, or people seeking health care, also have implicit knowledge they bring to the clinical setting.

Some of the knowledge brought in from people seeking treatment is the inner sense that “something is wrong with me”. Without the sense that something is wrong, we don’t seek healthcare, and this can explain why problems like bowel cancer can go unnoticed until the disease is in an advanced state – because symptoms are either very subtle, or not present. With low back pain we know that for most people the sense that “something is wrong” is almost immediate, but may not evolve into treatment-seeking until the problem either doesn’t follow the typical path of recovery, or the pain begins to interfere with what’s important in daily life (Ferreira, Machado, Latimer, Maher, Ferreira, & Smeets, 2010).

We acquire the idea of “something is wrong with me” from personal experience (that queasy feeling just before you get seasick), from others around us (you’re looking really pale today, are you OK?), and from broader society (if your pain persists, see your health professional). But, from some of the qualitative studies I’ve been reading, I think we really start to notice and do something about our “something is wrong with me” intuition once we can’t do things that are important to us and help to define our sense of self (Darlow, Brown, Lennox Thompson, Hudson, Grainger, McKinlay & Abbott, 2018).

It’s clear to me that both the person seeking help and the clinician hold tacit knowledge, and that this knowledge/information is likely to influence clinical reasoning. And some of the implicit knowledge in both clinician and patient changes without either party recognising that’s what has happened.

Back to clinical reasoning and meaning making.

Something I noticed when developing my theory of living well with chronic pain was that many people with ongoing pain learn about the effects on daily doing by themselves (Lennox Thompson, Gage & Kirk, 2019). What I mean by this is they establish what they can and can’t do in mini-experiments (experiences) each day. This experimentation and experience is strongly influenced by the person’s interpretation of what the pain means – and the confidence they have to find ways to cope or deal with pain. Because so much of our knowledge about pain is based on acute pain that generally settles down quickly, it’s unsurprising that some interpretations of persistent pain go awry.

Given the impact of persistent pain is firstly on being able to do what’s important in a person’s life, it makes sense to me that our clinical reasoning should incorporate an understanding of what the person needs and wants to do. It also makes sense to me that we need to understand the person’s current perspective: their beliefs, assumptions and experience of what pain has interfered with. This doesn’t mean that the person’s perspective is 100% accurate with respect to what is going on in their body, because as I pointed out above, many of our beliefs about “what is wrong with me” are based on social constructs. Having said that, it doesn’t mean our clinical interpretation is any more “accurate” – it does, however, mean that until our perspectives align, we’re likely to have trouble developing a shared meaning of the problem. As Arntzen points out “there is a tendency in person-centered occupational therapy practice to consider only the patient-articulated experience and not the multiple layers of embodiment and co-construction of meaning within the therapeutic relationship” (Arntzen, 2018).

One form of clinical assessment, perhaps one that’s under-used, is as Arntzen (2018) describes, the ongoing dialogue between a clinician and the person as the person enacts movements or engages in occupations. This kind of meaning making involves physical and cultural contexts (I may visit a cafe with my client to see how she navigates the tables and people, how she stands and then sits while drinking her coffee, and how she moves from this location to her car); it involves conversations with her about what is going through her mind as she encounters these situations; I may change the location of our next session on the basis of interpreting her performance in this context, adapting my voice, my body language to convey my assessment of this performance.

At the same time, the person I’m working with is also making meaning of how she managed in this situation. From my nonverbal and verbal response to what she does, she may infer that I think she’s doing fine, or that I’m worried about her capabilities. You’ll notice that much of this implicit shared meaning making is not verbal – it’s inference, and may well be inaccurate.

I really like Arntzen’s description of the way clinician and person can work together to develop a shared understanding of “the problems” – I’m quoting it whole:

An embodied intersubjective reasoning can be about questioning how the patient senses their changed body during performance and what it means for his or her ability or obstacles to act, learn, and change. This mode of reasoning can help the occupational therapist problematizing the patients’ performance, capabilities, and possibilities as an interrelated process between action failure, lived habitual practice, and ongoing and shared meaning-making.

Arntzen, 2018

I also love this depiction of therapy: Therapy is a context- specific dialogue between two interpretive, embodied agents, in which the outcomes of their relationship are not given in advance (Arntzen, 2018).

How can all clinicians use this perspective?

While Arntzen is an occupational therapy commentator, and I have framed this post through an occupational therapy lens, I think there is much that other movement and doing-oriented clinicians can draw on. The “ambiguous body” is also core to much of physiotherapy: the person’s experience of being within a body with its attendant limitations, and the body through which goals and aims and life is lived. The ambiguity is particularly relevant in pain where “not being myself” dominates the person’s sense of self – because the experience of pain and movement renders familiar actions as different and needing more attention than usual, or failing where it hadn’t before. Doing is disrupted, and therefore “being” the person I know myself to be is also disrupted. The way the person experiences his body can be influenced by an empathic clinician, to help him recognise changes, or become aware of a return to familiarity.

Arntzen (2018) also refers to tools or the things we use during daily doing – the toothbrush, the car, the clothing we wear, the phone we use that now doubles as computer, camera, aide memoir. Although we can think of these things as “things” have you noticed that you talk about “my phone”, “my car” – and the choice of phone or car situates you in your social environment. If you’ve ever picked up another person’s phone by accident, it just doesn’t feel right even before you recognise that it’s not your own! Occupational therapists incorporate “things” as part of enabling occupation, as do physiotherapists who may incorporate walking aids, temporary splints, or use gym equipment as part of therapy. I think it’s worth considering how the person experiences these things – are they integrated into a sense of self? (think of those tatty neoprene wrist splints worn for months, if not years; and also ponder the gym equipment that still seems alien even after completing a six week rehabilitation programme).

Finally, the crucial element of what we attend to during therapy – and the things we focus on and draw the person to notice – is about our own embodied presence. Arntzen says “Through moment-to-moment interaction, the therapist can have an effect on what becomes foreground and what is background for the patient during the act. The therapist may support or hinder the patient’s habitual practice, or may facilitate or hold back the patient’s own capability to explore new strategies, develop compensatory techniques, and find alternative solutions” (Arntzen, 2008). I’ve often described this process when teaching about eliciting automatic thoughts during movements (eg riding a bike or walking over a slippery floor) – if we attend to “purity of movement” or biomechanics or some externalised idea of how someone ought to do something, we’re likely to elicit more of that and it may be unhelpful. If we collaborate with the person and interconnect we’re just as likely to learn from him as he is from us. I like Schell’s (2014) description of this form of clinical reasoning: ecological professional reasoning.

Concluding

To conclude this lengthy post, I think too often clinicians have viewed their role as dominant, and what they say or ask the person to do as the primary therapeutic agent. I also think there’s a reason someone seeks help from a clinician. Relying only on one form of knowledge without integrating other forms (from the other person, using only language, being primary active agent etc) doesn’t seem to represent what actually goes on in therapy.

Many people with persistent pain learn what they can and can’t do on the basis of experiments that (often, at least in our most disabled people) lead to failure and recognising “I can’t do that any more”. Our approach has been to administer corrective exercises, experiences in moving differently, but we may well have forgotten both the contextual nature of doing and the experiential interpretation made by the embodied person. If we want to help people return to “feeling like themselves” maybe we need attend more carefully to the “what it is like” to experience this new experience, and then support the person to experiment in their own context. I’d call this knowledge translation, or perhaps occupational therapy.

Arntzen, C. (2018). An embodied and intersubjective practice of occupational therapy. OTJR Occupation, Participation and Health, 38(3), 173–180. https://doi.org/10.1177/1539449217727470

Benedetti, F., & Amanzio, M. (2011). The placebo response: How words and rituals change the patient’s brain. Patient Education and Counseling, 84(3), 413-419. doi:http://dx.doi.org/10.1016/j.pec.2011.04.034

Brooks, R., & Parkinson, S. (2018). Occupational formulation: A three-part structure. British Journal of Occupational Therapy, 81(3), 177–179. https://doi.org/10.1177/0308022617745015

Darlow, B., Brown, M., Thompson, B., Hudson, B., Grainger, R., McKinlay, E., & Abbott, J. H. (2018). Living with osteoarthritis is a balancing act: an exploration of patients’ beliefs about knee pain. BMC Rheumatology, 2(1), 15.

Ferreira, M. L., Machado, G., Latimer, J., Maher, C., Ferreira, P. H., & Smeets, R. J. (2010). Factors defining care-seeking in low back pain–A meta-analysis of population based surveys. European Journal of Pain, 14(7), e1-e7. doi:http://dx.doi.org/10.1016/j.ejpain.2009.11.005

Lennox Thompson, B., Gage, J., & Kirk, R. (2019). Living well with chronic pain: a classical grounded theory. Disability and Rehabilitation, 1-12. doi:10.1080/09638288.2018.1517195

McCambridge, J., Witton, J., & Elbourne, D. R. (2014). Systematic review of the Hawthorne effect: new concepts are needed to study research participation effects. Journal of Clinical Epidemiology, 67(3), 267–277. https://doi.org/10.1016/j.jclinepi.2013.08.015

Quintner, J., & Cohen, M. (2016). The challenge of validating the experience of chronic pain: the importance of intersubjectivity and reframing. In Meanings of Pain (pp. 281-293). Springer, Cham.

What’s the biggest barrier to learning more?


Reading and engaging with clinicians online and face-to-face, it’s clear to me that effectively integrating psychosocial factors into daily clinical reasoning, especially amongst physical or manual therapists, is a real challenge. There’s enough research around showing how poorly these factors are identified and then factored in to change what we do and how we do it for me to be convinced of this. What intrigues me, though, is why – given psychosocial risk factors have, in NZ, been around since 1997 – it’s still a problem.

It’s not ignorance. It’s not holding an alternative viewpoint. It’s not just that clinical reasoning models don’t seem to integrate these factors, or that our original training kinda partitioned the various “bits” of being human off – I think that it’s probably that we think we’re already doing well enough.

Image result for dunning kruger effect

This effect has a name – Dunning-Kruger effect. Now, don’t be put off by this term, because I know in some social media circles it’s used to bash people who are  maybe naive, or haven’t realised their lack of knowledge, and it can feel really awful to be told “well actually you’re ignorant”, or “you’re inflating your skill level”.  The thing is, it’s a common experience – we all probably think we’re great car drivers – but in reality we’re all pretty average.

The same thing occurs when we consider our ability to be:

  • empathetic
  • responsive
  • good listeners
  • client-centred
  • collaborative

Another important effect found in clinicians is that we believe our experience as clinicians means we’re better at aspects of clinical care, and especially at clinical reasoning. Over time we get better at recognising patterns – but this can actually be a problem for us. Humans are excellent at detecting patterns but as a result we can jump to conclusions, have trouble stopping ourselves from fixating on the first conclusion we draw, begin looking for things to confirm our hunch, overlook things that don’t fit with the pattern we’ve identified, and basically we begin to use stereotypes rather than really looking at the unique person sitting in front of us (see Croskerry, Singhal & Mamede, 2013a, b).

The effect of these biases, and especially our bias towards thinking we do better than we actually do (especially regarding communication skills and psychosocial factors) means we’re often completely unaware of HOW we communicate, and HOW poorly we pick up on psychosocial factors.

So often I’ve heard people say “Oh I use intuition, I just pick up on these psychosocial issues” – but the problem is that (a) we’re likely to over-estimate how well we pick up on them and (b) our intuition is poor. The risk for our patients is that we don’t identify something important, or alternatively, that we label something as a psychosocial risk factor when it’s actually irrelevant to this person’s problem.

Clinical reasoning is difficult. While recognising patterns becomes easier over time because we have a far broader range of patterns we’ve seen before, at the same time

  • research is expanding all the time (we can be out of date)
  • we can get stuck prematurely identifying something that isn’t relevant
  • we get hooked in on things we’ve just read about, things that happen rarely, things that remind us of something or someone else

Hypothetico-deductive reasoning is an alternative approach to clinical reasoning. It’s an approach that suggests we hold some ideas about what’s going on in our mind while collecting more information to test whether this is the case. The problem here is that we look for information to confirm what we think is happening – rather than looking for something to disconfirm, or test, the hypothesis we hold. So, for example, we might observe someone’s pain behaviour and think to ourselves “oh that person is doing that movement because of a ‘dysfunctional movement pattern’. We can assume that the reason for this movement pattern is because of underlying dysfunction of some sort – but we fail to test that assumption out to see whether it might in fact be a movement pattern developed because someone told the person “this is the way you should move”, or the person is moving that way because of their beliefs about what might happen if they move differently.

The problem with intuition and these other cognitive biases is that they simplify our clinical reasoning, and they reduce effort, so they’re easy traps to fall into. What seems to help is slowing down. Deliberately putting a delay in between collecting information and making a decision. Holding off before deciding what to do. Concurrently, we probably need to rely less on finding “confirming” information – and FAR more on collecting information across a range of domains, some of which we may not think are relevant.

That’s the tough bit. What we think is relevant helps us narrow down our thinking – great for reducing the amount of information we need to collect, but not so great for testing whether we’ve arrived at a reasonable conclusion. My suggested alternative is to systematically collect information across all the relevant domains of knowledge (based on what’s been found in our research), wait a bit and let it settle – then and only then begin to put those bits and pieces together.

Why doesn’t it happen? Well, we over-estimate how well we do this assessment process. We do jump to conclusions and sometimes we’re right – but we wouldn’t know whether we were right or not because we don’t check out alternative explanations. We’re pushed by expectations from funders – and our clients – to “set goals” or “do something” at the very first assessment. We feel guilty if we don’t give our clients something to take away after our initial assessment. We want to look effective and efficient.

Great quote?

For every problem, there is a solution that is simple, elegant, and wrong. H.L. Mencken.

If you’d like to question your own practice, try this: Record your session – and transcribe that recording. Notice every time you jump in to give advice before you’ve really heard your client. Notice how quickly you form an impression. Examine how often you look for disconfirmation rather than confirmation. See how often you ask about, and explore, those psychosocial factors. It’s tough to do – and sobering – but oh how much you’ll learn.

Croskerry, P., Singhal, G., & Mamede, S. (2013). Cognitive debiasing 1: origins of bias and theory of debiasing. BMJ Quality & Safety, 22(Suppl 2), ii58-ii64. doi:10.1136/bmjqs-2012-001712

Croskerry, P., Singhal, G., & Mamede, S. (2013). Cognitive debiasing 2: impediments to and strategies for change. BMJ Quality & Safety, 22(Suppl 2), ii65-ii72. doi:10.1136/bmjqs-2012-001713

Back to basics about psychosocial factors and pain – iv


Part of the definition of pain is that it is “a sensory and emotional experience” – in other words, emotions of the negative kind are integral to the experience of pain. Is it any wonder that poets and authors have written so eloquently about the anguish of unrelieved pain? As I write this, I’ve been pondering the way “psychosocial” has been used when discussing pain, as if those factors aren’t experienced by “normal” people, as if the way we feel about pain and the way people who struggle with their pain feel are two entirely different things.

Chris Eccleston, someone I admire very much, writes about a “normal psychology of chronic pain” and makes some incredibly useful points: that pain is a normal feature of human life. Pain is an everyday occurrence (watch kids playing in a playground – every 20 minutes kids communicate about pain, Fearon et al, 1996). In New Zealand one in five people report experiencing pain lasting six months or longer. Pain really is all around us – and it’s normal and indeed part of the experience itself, to feel negative emotions such as fear, anger, sadness, anxiety, and such when we’re sore.

So why have emotions been lumped in with “other factors” as part of the negative way psychosocial factors are interpreted today? I personally think it’s partly a hangover, in NZ at least, from the way our stoic forebears viewed “weakness”. There wouldn’t be many families in New Zealand who haven’t heard something like “man up”, or “big boys don’t cry”, or “pull yourself together” with great All Blacks who played on despite broken ribs or arms – who didn’t give in when they were injured being held up as examples we should emulate. At the same time pain isn’t given much space in our health professional training programmes – and when it is, it’s primarily viewed in a neuroanatomical way, as we’re taught about spino-thalamic tracts, and nociceptors, and not much else. In fact, I think the gate control theory is still being taught as the main theory in some programmes (despite it being revised and replaced with more sophisticated models).

So what is normal? I really like Acceptance and Commitment Therapy, as you’ve possibly noticed. Amongst one of the many reasons I like it so much is its view of suffering. Within ACT, being psychologically inflexible is the problem – that is, working hard to avoid or control experiences we don’t want, getting caught up in thoughts as if they’re Truth instead of our mind’s opinion of things, being attached to someone’s idea of who and what we are, living in the past or predicting the future, and failing as a result to take actions that line up with what our personal values are. When we get stuck thinking there’s only one way to deal with a situation, and when we forget about what’s important in our lives because we’re working so hard to avoid certain experiences – these aren’t seen as pathological, but instead are just part of the way our mind/language and experience tangle us up. The beauty is that there are ways out of being stuck but they’re counter-intuitive.

What do I mean? Well if we all have negative emotions about pain, why do only some of us struggle with that experience and get stuck? For some people it’s because they’re trying so hard not to feel pain that they spend time and energy doing things to control it and in the process stop doing things that matter. Think of the many appointments and the ups and downs of hope that it will all go away with this magic thing – then despair as it doesn’t work. Just the amount of time people spend waiting for and attending appointments can take time away from being with family, working, living…Now to me, this is not psychopathology. This is what normal minds do – try to fix a problem using strategies that have always worked in the past.

At the same time, given pain is a negative experience, doesn’t it make sense to monitor what went on last time you tried to lift that box, go to work, drive the car… AND doesn’t it make sense to anticipate what might go wrong if you try it again? This isn’t about being depressed, anxious or any other kind of pathology – this is just what we’ve learned to do, and our minds are trying incredibly hard to make it work again.

When I mentioned that a solution might be counter-intuitive, what I mean is recognising that trying to control or avoid an experience that comes with us wherever we go because it’s part of us, can trip us up. Instead, we might do better if we soften our attempts to control or avoid our experience of pain. Maybe spending time exploring pain and doing things alongside pain is possible – especially if the things we want to do are important to us. Don’t believe me? Think about marathon runners – they feel the pain (hit the wall) and still keep running! Why? Because it’s important to them to get to the end.

Now I’m not suggesting that ALL people will find this approach helpful, and I’m NOT denying that many people with persistent pain experience depression, anxiety, rotten sleep and generally feel demoralised. What I AM saying is that if we approach everyone with the misguided idea that psychosocial factors exist only in “those people”, we’re wrong. Any one of us will experience negative emotions if pain is present – and even more if pain persists. This is a normal response to a challenging and inherently aversive experience. Of course, if we’ve experienced depression, adverse life events, turmoil in our home and work life, and the stigma of not being believed, the potential to then become angry, depressed, and fed up is only greater. Let’s not make a negative experience worse by stigmatising people with the notion that “psychosocial factors” makes them any different from anyone else.

 

Eccleston, C. (2011). A normal psychology of chronic pain. Psychologist, 24(6), 422-425.

Fearon, I., McGrath, P.J., Achat, H. (1996). ‘Booboos’: The study of everyday pain among young children. Pain, 68, 55-62.

Vowles, K. E., Witkiewitz, K., Levell, J., Sowden, G., & Ashworth, J. (2017). Are reductions in pain intensity and pain-related distress necessary? An analysis of within-treatment change trajectories in relation to improved functioning following interdisciplinary acceptance and commitment therapy for adults with chronic pain. Journal of consulting and clinical psychology, 85(2), 87.

The “Subjective” – and really hearing


I’m not a physiotherapist. This means I don’t follow the SOAP format because it doesn’t suit me. The first letter is intended to represent “subjective” – and when I look up the dictionary meaning of subjective and compare it with the way “subjective” notes are thought about, I think we have a problem, Houston.

Subjective is meant to mean “based on personal feelings” or more generally “what the person says”. In the case of our experience of pain, we only have our personal feelings to go on. That is, we can’t use an image or X-ray or fMRI or blood test to decide whether someone is or isn’t experiencing pain.

Now the reason I don’t like the term “subjective” when it’s part of a clinical examination is that so often we contrast this section with so-called “objective” findings.  Objective is meant to mean “not influenced by personal feelings”, and is intended to represent “facts” or “the truth”. Problem is… how we determine truth.

Let’s think about how the information we obtain fits with these two ideals, and how we use it.

Subjective information is all the things we ask a person about – their thoughts, beliefs, feelings, understanding and their own experience. Subjective information might even include the person’s report of what they can and can’t do, how they feel about this and what their goals are.

Objective information, on the other hand, is all the things we as clinicians observe and measure. Now here’s my problem. By calling this information “objective” we’re indicating that we as clinicians hold a less-than-subjective view of what we see. Now is that true? Let’s think about the tests we use (reliability, validity anyone?). Think about the choices we make when selecting those tests (personal bias, training variability, clinical model…). Think about the performance variables on the day we do the testing (time of day, equipment and instruction variability, observational awareness, distractions, recording – oh and interpretation).

Now think about how that information is used. What value is placed on the objective information? It’s like a record of what actually was at the time. If you don’t believe me, take a look at what’s reported in medico-legal reporting – and what gets taken notice of. The subjective information is often either overlooked – or used to justify that the client is wrong, and what they can actually do is contained in the “objective”.

Given the predictive validity of a person’s expectations, beliefs and understanding on their pain and disability over time, I think the label “subjective” needs an overhaul. I think it’s far more accurate to call this “Personal experience”, or to remove the two labels completely and call it “assessment”. Let’s not value our own world view over that of the people we are listening to.

How do we really hear what someone’s saying? Well, that’s a hard one but I think it begins with an attitude. That attitude is one of curiosity. You see, I don’t believe that people deliberately make dumb decisions. I think people make the best decisions they can, given the information they have at the time. The choices a person makes are usually based on anticipating the results and believing that this option will work out, at least once. So, for example, if someone finds that bending forwards hurts – doesn’t it make sense not to bend over if you’re worried that (a) it’s going to hurt and (b) something dire is happening to make it hurt? In the short term, at least, it does make sense – but over time, the results are less useful.

Our job, as clinicians, is to find out the basis for this behaviour, and to help the person consider some alternatives. I think one of the best ways to do this is to use guided discovery, or Socratic questioning to help both me and the client work out why they’ve ended up doing something that isn’t working out so well now, in the long term. I recorded a video for the Facebook group Trust Me, I’m a Physiotherapist (go here for the video) where I talk about Socratic questioning and Motivational Interviewing – the idea is to really respect the person’s own experience, and to guide him or her to discover something about that experience that perhaps they hadn’t noticed before. To shed a little light on an assumption, or to check out the experience in light of new knowledge.

Learning Socratic questioning can be tricky at first (Waltman, Hall, McFarr, Beck & Creed, 2017). We’re not usually trained to ask questions unless we already know the answer and where we’re going with it. We’re also used to telling people things rather than guiding them to discover for themselves. Video recording can be a useful approach (see Gonsalvez, Brockman & Hill, 2016) for more information on two techniques. It’s one of the most powerful ways to learn about what you’re actually doing in-session (and it’s a bit ewwww at first too!).

We also really need to watch that we’re not guiding the person to discover what we THINK is going on, rather than being prepared to be led by the client as, together, we make sense of their experience. It does take a little time, and it does mean we go at the pace of the person – and we have to work hard at reflecting back what it is we hear.

So, “subjective” information needs, I think, to be valued far more highly than it is. It needs to be integrated into our clinical reasoning – what the person says and what we discover together should influence how we work in therapy. And we might need to place a little less reliance on “objective” information, because it’s filtered through our own perspective (and other people may take it more seriously than they should).

 

Gonsalvez, C. J., Brockman, R., & Hill, H. R. (2016). Video feedback in CBT supervision: review and illustration of two specific techniques. Cognitive Behaviour Therapist, 9.
Kazantzis, N., Fairburn, C. G., Padesky, C. A., Reinecke, M., & Teesson, M. (2014). Unresolved issues regarding the research and practice of cognitive behavior therapy: The case of guided discovery using Socratic questioning. Behaviour Change, 31(01), 1-17.
Waltman, S., Hall, B. C., McFarr, L. M., Beck, A. T., & Creed, T. A. (2017). In-Session Stuck Points and Pitfalls of Community Clinicians Learning CBT: Qualitative Investigation. Cognitive and Behavioral Practice, 24(2), 256-267.