Resilience/Health

When therapists get hurt


“Physician, heal thyself” – usually used to suggest that the person should fix their own problems before trying to fix someone else. And when a therapist gets hurt all the armchair critics (social media proclamists) go off pointing the finger and telling that person what to do – even when the therapist is doing exactly what evidence suggests is the right thing to do.

Adam Meakins has hurt his back while lifting weights in the gym – he’s documenting his progress on social media, which I think is both a very brave thing to do and also something I’d love to see more of. If you want to follow his progress, head to The Sports Physio on Facebook where he’s posted footage of the onset, and now Days 1 and 2.

Why do I think it’s brave? Well because Adam’s outspoken and highly visible on social media. That means anything and everything he does about his LBP is likely to be scrutinised in detail. All manner of opinions have already been put forth. Diagnoses made (yeah, I know – over the interwebs…), and so many treatment options offered!

Adam’s predicament gets much more attention than Mrs Jones down the road who hurt her back the same day. Yet Adam knows what to do, is doing it, and holding strong to what research suggests is best.

Mrs Jones, on the other hand, is likely subject to some of the opinions that Adam’s getting (go on, take a look, especially on Instagram and Twitter) but without the background and experience Adam has to draw on. No wonder Mrs Jones feels confused.

Adam is brave because, as he pointed out today, having LBP means your mind leaps to unhelpful conclusions, often “thinks the worst” and in the dark of the night, it’s probable that doubts about whether he’s doing the right thing creep in. And if Adam’s recovery is slower than usual, I can hear the chorus of bystanders roar for his blood “You didn’t do what I said you should do”

Because isn’t it peculiar, and common, that when recovery doesn’t follow the standard trajectory, it’s the person’s fault…

Think of Mrs Jones – if her recovery goes the way so many people’s recovery goes and burbles along with flare-ups and periods where it settles, then she’s likely to carry on seeing at least one clinician, probably more. She’ll likely get a whole range of different ways to manage her low back pain – but usually starting with one approach and getting more of it until the clinician decides to change tack, and then onto another one until that clinician decides it’s not working and changes tack….And along the way she’ll acquire labels like “catastrophiser” or “avoidant” or “noncompliant”.

I also said that I’d love more clinicians to post about their recovery. I’ve seen a few, but couldn’t we do more? Why? Because showing how clinicians also “think the worst”, worry, have trouble sleeping, want to keep going but find it tough – despite our knowledge of pain, and all our experience working with people who have pain – is good for us as clinicians.

Because if you’ve never had a bout of back pain it’s relatively easy to think that the way a person reacts to their pain is abnormal. The label “catastrophising” gets bandied about, along with all the other psychosocial factors that can often get used and abused in a way that lays the fault for the person’s predicament on them.

But back pain is really common. Most of us will have a bout at some point in our life – maybe more severe than Adam’s, maybe less severe, maybe associated with heavy lifting as Adam’s was, maybe just bending to pick up a pair of socks. Some of us will be really fit like Adam, others of us will be less fit.

Back pain isn’t very choosy and this is why we haven’t yet found a way to prevent it from ever happening, we can only work with the person to prevent it hanging around and getting in the way of life.

Being honest enough to show that clinicians are human too helps other clinicians rethink the “them and us” divide that is common between people seeking help, and those who would offer help. Because how often do we hear that Mrs Jones was unfit, probably lazy, had a bad lifestyle, ate the wrong foods, did no exercise, and it was probable that she’d develop a back pain. Yet Adam is pretty fit, lives a healthy lifestyle, is certainly not lazy, and like Mrs Jones does not deserve a low back pain.

I hope that Adam doesn’t get the advice I’ve heard given to so many people: get fit, change your lifestyle, get back to work, do more. Mrs Jones might be working two physically demanding jobs (cleaning, and waiting tables). She might walk 20 minutes to get to the bus-stop, and is on her feet all the time she’s at work. She might leave home at 6.00am, get back at 5.00pm to prepare a meal for the rest of her household, then go out again for another three or four hours to her second job, finally arriving home to sleep at 9.00pm. And some youngster suggests she needs to “prioritise herself” and “do exercise”! Who else is going to do what Mrs Jones does for her family?

Finally, I really hope that people offer Mrs Jones a lot more of an empathic response than Adam has had. Anyone experiencing pain needs support – and don’t need a whole bunch of well-intentioned advice from people who don’t know them personally. And some of the comments offered to Adam are not well-intentioned. What does that kind of vicious behaviour show to the general public?

Below – just a small selection of the longitudinal studies exploring the trajectories of back pain in the population. Worth looking at if you think you’ve got The Answer to What To Do – because so far it’s not working.

Canizares, M., Rampersaud, Y. R., & Badley, E. M. (2019, Dec). Course of Back Pain in the Canadian Population: Trajectories, Predictors, and Outcomes. Arthritis care & research, 71(12), 1660-1670. https://doi.org/10.1002/acr.23811

Chen, Y., Campbell, P., Strauss, V. Y., Foster, N. E., Jordan, K. P., & Dunn, K. M. (2018, Feb). Trajectories and predictors of the long-term course of low back pain: cohort study with 5-year follow-up. Pain, 159(2), 252-260. https://doi.org/10.1097/j.pain.0000000000001097

Gatchel, R. J., Bevers, K., Licciardone, J. C., Su, J., Du, Y., & Brotto, M. (2018, May 17). Transitioning from Acute to Chronic Pain: An Examination of Different Trajectories of Low-Back Pain. Healthcare (Basel, Switzerland), 6(2). https://doi.org/10.3390/healthcare6020048

Kongsted, A., Kent, P., Axen, I., Downie, A. S., & Dunn, K. M. (2016, May 21). What have we learned from ten years of trajectory research in low back pain? BMC Musculoskelet Disord, 17, 220. https://doi.org/10.1186/s12891-016-1071-2

Pico-Espinosa, O. J., Cote, P., Hogg-Johnson, S., Jensen, I., Axen, I., Holm, L. W., & Skillgate, E. (2019). Trajectories of Pain Intensity Over 1 Year in Adults With Disabling Subacute or Chronic Neck Pain [Journal: Article]. Clinical Journal of Pain, 35(8), 678-685.

…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.

What to do about acute low back pain


I should add another line to that heading: in one easy step! And I’d be inundated with hits and if I could cash in on them I’d be rich! And wrong.

If there was a simple recipe for success, I’d expect that by now we’d have it. The very fact that SO MANY options for managing a bout of low back pain exist is a good reason for skepticism should you ever get tempted to take a headline like mine as a cause for celebration. However I do want to talk about acute low back pain because I think clinicians are often probably doing it wrong.

First of all, low back pain doesn’t include pain that also goes down the leg. Let’s get the definitions clear before we talk! In 2008 a Delphi study by Dione, Dunn, Croft, Nachemson, Buchbinder, Walker and colleagues (2008) developed two definitions: a minimal definition, and an optimal definition. These definitions were developed for epidemiological studies and the minimal definition is very simple – “In the past 4 weeks, have you had pain in your low back?” and “If yes, was this pain bad enough to limit your usual activities of change your daily routine for more than one day?”

from Dionne, Dunn, Croft, Nachemson, Buchbinder, Walker et al, (2008)

Now when it comes to defining a first bout of acute low back pain, Ardakani, Leboeuf-Yde & Walker (2019) raise some very interesting points: researchers investigating acute low back pain don’t clearly distinguish between the factors associated with the disease of low back pain (as they put it, the onset of the very first episode) from its recurring episodes – as they put it, “the continued manifestations of the “disease”.” In fact, in their systematic review for identifying risk factors from “triggers” (their term for subsequent episodes), they could find only one study dealing with the true incidence of first time low back pain – and this was low back pain caused by sports injury. All the remaining studies either explored new episodes, or recurring episodes. The major problem with these studies? They didn’t define how long a person should have had no low back pain at baseline. And given many of us develop back pain in adolescence (see Franz, Wedderkopp, Jespersen, Texen and Leboeuf-Yde, 2014, or Jones & MacFarlane, 2005) for example) it’s probable that studies investigating those over 18 years old will include a lot of people who have had that first bout already.

The trajectories for those of us who do develop low back pain are also reasonably murky because of the challenges around definitions, and there are several studies with slightly different results as you’d expect. Essentially, though, most researchers find that there are three or four patterns that emerge from longitudinal studies: lucky ones who have one bout and no or low levels of pain thereafter; those who have persisting mild pain, those who have fluctuating bouts over time, and those who develop persistent and severe pain. Chen and colleagues (2018) found that “lower social class”, higher pain intensity at the beginning, the person’s perceptions of more challenging consequences and longer pain duration, and greater “passive” behavioural coping were most significantly associated with the more severe trajectory over five years.

So, what does this mean for clinicians – and how well are we doing?

Acute low back pain can really frightening for people, especially if the pain is severe. As clinicians generally choose this work because we care about people, we get hooked into wanting to reduce pain and help. There’s nothing wrong about this – unless it means we also get hooked into trying to offer something we cannot. We’re inclined to believe that people seek help for their back pain because of the pain – but as Mannion, Wieser & Elfering (2013) found from a study of over 1,000 people with back pain at the time of the survey, 72% hadn’t sought care over the previous four weeks; 28% had sought care – and most from more than one provider. Women were more likely to seek care, those who had experienced more previous bouts, those who had trouble with activities of daily living and more trouble with work activities. While pain intensity did feature, it wasn’t as much of a predictor as many clinicians would expect. Indeed, an earlier meta-analysis by Ferreira and colleagues (2010) found that disability was a stronger predictor for seeking treatment than pain intensity.

So what do clinicians focus on? I suspect, though I aim to be proven incorrect, that almost every clinician will ask “what is your pain intensity on a scale from 0 – 10?” Frankly, this question is one that irritates me no end because how on earth do you rate pain? Seriously. Yes, there are a lot of clinicians who then ask about activities a person wants to be able to do (yay!) though when we look at the treatments offered, I wonder how many follow through with practical goal-setting for daily activities like getting shoes and socks on, carrying the groceries, sitting while driving the car or at work… And treatments? the arguments on social media between clinicians would be fun to watch if only they weren’t accompanied by such vehemence!

What I don’t see are conversations about how we help people recognise that they’re likely to follow one of those four trajectories, and what we do to help people self manage a life alongside low back pain.

I don’t see much attention paid to helping people sleep well.

Lots of conversations about pain neurobiology – in an attempt to use this explanation to bring someone on board to engage in treatments.

I don’t see a lot of discussion about how to ask about the person’s main concern – perhaps it’s nothing to do with pain, but more about “my niece is coming to visit and I’m not sure I can cope with entertaining her and managing my back pain”, or “we’re coming up to the busy time at work and I can’t not go in, but when I get home I’m trashed, how can I manage that?”, or “Monday’s are our busiest day, and I have to keep going because the team needs me, what do I do?”

I wonder whether clinicians could be persuaded to get out of the way and stop confusing people with recipes or algorithms or “special exercises” that “must be done this way” – I wonder if we could offer some very simple steps: specific answers to the person’s main concerns (best form of reassurance there is!); goal setting around the things the person needs and wants to do over the first six to eight weeks; sleep strategies including some mindfulness because that’s likely to help long-term; and lots of encouragement as the person returns to activity. Developing a relationship with the person doesn’t need lots of prescriptive steps or cookie cutter programmes, it does mean listening, showing trust in the person’s own capabilities, and willingness to let go of a few sticky thoughts we’ve acquired during our training. Maybe 2021 could be the year clinicians get back to basics and begin to support resilience in the people we see – firstly by showing them that we trust they have the capabilities.

Ardakani, E. M., Leboeuf-Yde, C., & Walker, B. F. (2019). Can We Trust the Literature on Risk Factors and Triggers for Low Back Pain? A Systematic Review of a Sample of Contemporary Literature. Pain Res Manag, 2019, 6959631. doi: 10.1155/2019/6959631

Dionne, C. E., Dunn, K. M., Croft, P. R., Nachemson, A. L., Buchbinder, R., Walker, B. F., . . . Von Korff, M. (2008). A consensus approach toward the standardization of back pain definitions for use in prevalence studies. Spine, 33(1), 95-103.

Franz, C., Wedderkopp, N., Jespersen, E., Rexen, C. T., & Leboeuf-Yde, C. (2014). Back pain in children surveyed with weekly text messages-a 2.5 year prospective school cohort study. Chiropractic & Manual Therapies, 22(1), 35.

Jones, G. T., & MacFarlane, G. J. (2005). Epidemiology of low back pain in children and adolescents. Archives of disease in childhood, 90(3), 312-316.

Mannion, A. F., Wieser, S., & Elfering, A. (2013). Association between beliefs and care-seeking behavior for low back pain. Spine, 38(12), 1016–1025

Becoming resilient


Rehabilitation professions are about helping people recover from illness to return to what matters in life. Sometimes as I read the myriad social media posts on ways to help people with pain, I wonder what kind of life rehabilitation professionals live themselves. Does our focus on what’s done during rehabilitation represent the way people live in everyday life?

I suspect that because rehabilitation has emerged from a medical model, much of our expectations and the framework for our work has remained in a “fix-it” or “there you go, good as new” mindset. A kind of short-term, out the door and back home lens, exacerbated by hospital adminstrators and policy developers needs to get people to leave hospital so as not to clog the beds.

Rehabilitation is often provided for people recovering from accidental injury, at least in NZ. These services consist of lots of physiotherapy – mainly exercise prescription; vocational rehabilitation – mainly time-frame expectations for the number of hours a person should be working, with adjustments made to tasks and some equipment; psychology – possibly cognitive behavioural approaches, but no specialist rehabilitation psychology yet in NZ.

The main problems with rehabilitation for persistent pain is that while provision for people receiving compensation is available (very little for those not receiving ACC), it’s often located away from where people live their lives. Even in the workplace, much vocational rehabilitation is undertaken by clinicians who are focused on helping the person return to this job only, not respond to future developments.

I think rehabilitation professionals could take a few leaves out of an approach promoted by Steven Hayes, Professor of Psychology at University of Nevada. In a recent paper he and Stefan Hofmann and Joseph Ciarrochi wrote, he proposes an “extended evolutionary meta-model” (EEMM) could provide unity to a process-based approach to therapy (Hayes, Hofmann & Ciarrochi, 2020). Much of the paper addresses concerns about the DSM V and its abysmal record of identifying underlying aetiologies for common mental health problems – and I would argue that similar concerns apply to problems inherent in attempting to treat pain. The aetiology of a pain problem probably has little in the way of influencing how a person responds to the experience.

What appeals about the EEMM is that it builds towards recognising that “defined processes of change are biopsychosocial functions of the
person in context, as distinguished from the procedures, interventions, or environmental changes that engage such functions.”

When the human genome was first mapped, I remember the enthusiasm had for finally, finally, we’d find “the genes for…” [name your disease].

Sad to say, behaviour isn’t as straightforward as that – as Hayes and colleages point out “behavior results from a diverse set of evolving dimensions and levels that include not only genes, but also many other processes. As a result, behavioral phenotypes that clearly involve genes are not necessarily genetic in a process of change sense.” Actually, many chronic diseases aren’t nearly as straightforward as we’d hoped (think type II diabetes, for example).

So what does an EEMM approach do for rehabilitation? I think we can begin to frame rehabilitation according to the foundations of evolution: to evolve, organisms need to have variability (otherwise the whole species dies out). To be resilient, and respond to what life throws at us, humans also need to have a wide repertoire of responses. This is one part of rehabilitation – to help people develop new response repertoires that fit their new circumstances. How well do we enable people to develop a broad repertoire of ways to do things?

Rehabilitation processes work to help people choose the most useful response for what’s needed in function: selection. Selection is a key part of evolution, because it allows the organism to choose a response from their repertoire to suit the circumstances. Translating to humans, given a context, people can choose a response that enables them to do what matters in their life. For example, knowing a range of ways to move an object from A to B means humans have learned to build the pyramids, and to construct Faberge jewelry. In rehabilitation, do we enable people to develop a range of responses, and do we help them work through a process of choosing well for a given context and purpose? Is a clinic the best place to learn how to choose well? Do our rehabilitation approaches incorporate motivational factors to engage people, so they can work out what’s important for their own life and values?

Retention is another process of evolution – people need to learn a range of responses, choose appropriately and know those responses well enough for them to be used when needed. Rehearsal, practice, habits and routines are the way humans have developed patterns that enable more brain space to be dedicated to choosing the best way to achieve a goal. Being able to effortlessly vary a response because it’s well-practiced is how elite sports athletes, professional dancers, musicians and performers do what they do despite the very different places they may need to do it. I think we possibly begin to do this, but often omit the patterning, the habitual practice in many different contexts that is needed to really retain variety.

Finally, evolutionary processes are about context. When the context changes, the most adaptive beings survive because they have a range of behavioural options to choose from, they know how to choose them, and the options are well-learned – and the choices they’ve made suit the new context. In rehabilitation, how well do we vary contextual demands? How often do we help people engage in what matters in their life in the person’s real world? Do we go walking across a range of different flooring surfaces, like the slippery shopping mall, the sandy beach, the rocky river-bank, the rugby field, the park? Do we mix it up with pace – fast and slow? Do we consider time of day? Do we think about the presence of sensory stimuli? Or the absence of sensory stimuli? Do we include contexts where there are lots of people – or very few, but they’re all focused on the one person? Do we think about the size, shape, fragility, wriggliness or preciousness of an object we’re hoping the person will lift?

To really help people flourish and respond to the future demands they’ll face, rehabilitation professionals might want to consider the EEMM, and begin to adopt a process-based approach to what we do. While some of the physical rehabilitation principles we use might not change, I think we could be far more creative and responsive to the processes involved in learning to adapt to altered circumstances. Maybe psychosocial flexibility is as important as muscle strength and control?

Hayes, S. C., Hofmann, S. G., & Ciarrochi, J. (2020). A process-based approach to psychological diagnosis and treatment:The conceptual and treatment utility of an extended evolutionary meta model. Clinical Psychology Review, 82. doi:10.1016/j.cpr.2020.101908

Springboard: Beginning to live life again


Springboard is a six week, 120 min once a week programme for people with pain. I developed this programme in the context of New Zealand’s Accident Compensation Corporation (ACC) community-based pain management services.

So, why use a group approach and what’s inside Springboard?

Pain can be such an isolating experience, and for many people, not only do friends and family not “get it” but neither do some of their health professionals! Living with pain, even for “just” a few months can lead to loneliness because most people don’t know what it is like to experience pain that doesn’t go away. Simply coming to a group where everyone else is in the same boat offers people a chance to be authentic about what it’s like. Connection with other people is so important – remember humans are a social species.

The second reason I love groups for this kind of work is that we get to share much more information and learning from one another than can be achieved in a one-to-one setting. As each person talks about their experience, others can relate “I’m the same”, or compare “I’m not like that”. Participants can share their wins and losses. They can contribute to help solve one and other’s problems. They can challenge one another in a way that health professionals who haven’t lived with pain can’t emulate.

If we look at Bandura’s social learning theory we can see that direct experience is the most powerful influence on self efficacy, and the second most powerful influence is vicarious learning. Being able to see how others approach the challenges of every day with pain gives participants a powerful learning tool.

What’s inside Springboard?

Springboard is based on ACT (Acceptance and Commitment Therapy) and also draws on motivational interviewing as a therapeutic stance. Rather than focusing on changing pain, the focus in Springboard is on learning ways to live life again, even in the presence of pain. In other words, Springboard is about beginning to be yourself again.

One of the most profound losses when a person experiences pain that doesn’t follow the “typical” trajectory is a loss of previously implicit assumptions. The body becomes more significant with pain – movements are attended to, daily activities are bounded by far more awareness than normal, assumptions about what a person can expect from him or herself are challenged. In turn, this awareness brings a loss of sense of “self”. Self concept is an idea about “what I can expect to do, be competent at, and what others believe I can do” – and when pain is present, these expectations are violated.

Springboard aims to help people take stock of their lives, decide what matters, and begin to move towards valued actions in the presence of pain. Opening up more of life than just attempting to get rid of pain and “go back to normal”.

The thing is, “normal” has gone – whether pain ultimately resolves or not. Because each person who has gone through this weird experience of pain that doesn’t obey the rules will remember what it was like when they had their pain, and the old certainty and belief that the body will do whatever it’s asked to do will have likely eroded.

So Springboard asks the questions: if pain was less of a problem for you, what would you be doing? What matters to you? How can we work together to get more of that – and in doing so, enrich your life, and the lives of those you care about.

Each session begins with a review of the “missions” all participants undertake in their own contexts. These are values-based actions that participants choose for themselves, and that will build towards being and doing what matters in life. In other words, making life bigger.

As participants review their progress, and share their successes – and challenges – all the other participants contribute ideas to solve the problems, celebrate the successes, encourage setting new actions and learn from one another.

Each of the six sessions has a focus.

  1. What do we know about pain? Sharing information each person has been given, and what sense they make of it. Generally working towards a common understanding of some of the mechanisms, some of the treatments people have tried, and getting perspective on how variable individual responses are to treatment. There is no single magic wand cure.
  2. How can we organise activity levels? AKA the “pacing” or activity management session. We share the various trajectories people have been on – the deactivation process, the boom and bust process, the push through until you gasp approach, the gradual increase approach, and the consistency or quota approach. Rather than telling people which is “the best” we look at the good and the not-so-good about each, using participant’s own examples. That way we can help people weigh up their options for the various contexts in which they live.
  3. Dealing with sticky thoughts and feelings. This is the “ACT” session – discussing cognitive defusion strategies, noticing, willingness, perspective taking, and finding wiggle room. Each session begins with a mindfulness “arrival” moment, so participants are familiar by this time with noticing that the mind likes to dictate. Participants begin to use “Choice point” as a creative way to notice what their mind is telling them, and choose an action to align with what matters to them in that context.
  4. Sleep is always a hot topic! In this session we discuss all manner of sleep strategies, and how/why sleep is such a problem and so important for people with pain. Our solutions are diverse – everyone has something to contribute – and again, we look at the good and not-so-good of each option.
  5. Who’s on your team? In this session, participants explore the many people they’ve interacted with because of their pain, all the people they’ve told their story to. We examine the various contributions these people make, and begin to look at how better to communicate in an authentic, respectful and “straight-up” way. Some participants bring family to this session as we build a list of who is on the team, and help the person with pain be the captain.
  6. Flare-ups, set-backs and pre-planning. The final session is about when things go wrong. Identifying things that disrupt newly-developed skills and habits, whether these are pain flare-ups, pain settling (yet, it’s a thing that can trip people up!), holiday routines, returning to work, new assessments – all the things that life holds! Participants work on drawing up their own pain management plan (written down so it can be pinned on the fridge!), and on a set-back plan or “can cope” card.

The real grunt work of this programme lies in the home-based missions each participant does. It’s in doing new things, taking small steps in a different direction, stopping to notice before acting, defusing and giving a moment of space before choosing what to do – these actions are reviewed at the beginning of every session and really form the core of what Springboard offers.

Over the next six weeks I’m putting the facilitator training for Springboard online. This will make the training available for more people, both in New Zealand and elsewhere. Keep watching out because I’ll make an early bird announcement very soon!

What do occupational therapists add to pain management?


I’ve struggled with professional identity from time to time, but after completing my PhD thesis looking at how people live well with pain, I’ve developed a new understanding of how occupational therapists add value in this area of practice.

Occupational therapists joke that “no-one knows what an occupational therapist does” – and sadly, that’s true. It’s not because what we do isn’t important, it’s because our view of people and the way we work with people differs from most health professions. Occupational therapists don’t treat disease per se, we work with people’s function and participation, with a person’s illness experience. We don’t fit inside a biomedical, disease-oriented model of humans.

This means an occupational therapist works with people using a process-oriented approach. This approach begins by understanding what a person values, what matters in their life, and how the person’s life context influences their participation. Occupational therapists are concerned with the daily minutiae of life: the way you clean your teeth, how you get to work, what you do for fun, the roles you undertake, the daily routine you follow, the things that make your life your own – not a facsimile of someone else’s.

In pain management/rehabilitation, occupational therapists are there to help people resume, or begin, a life that looks like their own. To integrate strategies into daily routines and habits. To contextualise the strategies other professionals introduce. We’re the professional who talks about the timing of exercise/movement practice – how to fit exercises into each day without compromising other important routines. The details of when and where and how exercises are done in the long term, for life, in life. We encourage people to look beyond the simple 3 x 10 and into the kinds of movement opportunities that hold meaning beyond the “it will help your pain”.

Occupational therapists translate what happens in clinic settings into the real, messy, chaotic and unpredictable worlds of the people we serve. When someone is learning to develop self compassion, occupational therapists work out what this might look like in the context of being a good father, or an efficient employee. When someone is developing effective communication skills, occupational therapists are there to review when, where and how these skills are brought into play with the kids, the uncle, the neighbour, the colleague. When someone needs to learn to down-regulate a sensitive nervous system, occupational therapists are there to help assess each setting, noticing the sensory load of a situation, problem-solving ways to remain engaged in what’s important without withdrawing or overloading.

When someone’s afraid of a movement, occupational therapists go into the real world to help that person begin to do that activity – our skills are there to titrate the level of difficulty not just around biomechanical demands, but also social, interpersonal, sensory, and cognitive loads. Ever wondered why a person can manage something really well in the clinic – but can’t do the groceries, go to a restaurant, stay with friends overnight, anywhere where the demands are different? Occupational therapists can help figure out why.

For those that don’t know, my profession has been established since the days of 1793, when Phillipe Pinel began what was then called “moral treatment and occupation”, as an approach to treating people with mental illness. In the US, a National Society for the Promotion of Occupational Therapy (NSPOT) was founded in 1917, and continued through the 1920’s and 1930’s until the Great Depression. Occupational therapy became more closely aligned with medicine as part of a rehabilitation approach to recovery with wounded soldiers, those with TB (in New Zealand especially), and those with chronic diseases. In fact, occupational therapy was a registered and protected health profession in NZ since 1945 (before psychology).

It was during the 1980’s and 1990’s that the profession began questioning the medical model – and during my training in the early 1980’s, Engel’s biopsychosocial model was promoted as an over-arching approach to viewing people. So for occupational therapists, this is our practice philosophy: to look at the whole person in context.

Occupational therapists are fully trained across both physical and mental health. Our profession is one of the very few that has retained this “whole person” model of health from its inception. The value of doing, being and becoming is at the centre of practice. The appreciation that people live in a physical and social context, and that people have biopsychosocial, cultural and spiritual aspects is central to practice.

Pain is a human experience that spans the biological, the psychological, the social, the spiritual. Pain can influence all of life. When life has lost meaning because it doesn’t look like the life a person had before pain – this is where occupational therapists practice the art and science of our work.

On values, culture and health


This week is Te Wiki o te Maori – and the theme is Kia Kaha te Reo Maori. For those readers not familiar with te reo, kia kaha translates to “be strong.” It’s a word people from Otautahi (Christchurch) have used a lot since 2010 and the first of the many events that have shaken (literally) our world since then. Te Wiki o te Maori is a week dedicated to celebrating and strengthening the use of Maori language in New Zealand.

While the week celebrates the language of Aotearoa, it also helps us tangata tiriti, or people of the Treaty of Waitangi, remember that we have a place in this whenua (land). It helps me remember the values that those of us living in Aotearoa hold dear.

The thing about culture is that many of us don’t even recognise that we have a culture. Cultures are the assumptions, practices, values, beliefs, habits, ways of being that we have absorbed without knowing we have (see here for a nice description of culture). We all live within more than one culture, irrespective of the colour of our skin – culture is not synonymous with ethnicity or “race.”

This year “Black lives matter” has erupted onto the consciousness of thousands of people around the world. It’s as if, for many people, the whole notion of equality vs equity has never before been a thing. And it’s this blindness to social differences that I want to discuss today.

Recently I’ve been talking about the way exercise is discussed amongst health professionals. I pointed out that not everyone enjoys the gym, and that 3 x 10 sets of exercises is possibly the best way to kill anyone’s enthusiasm for movement. I also argued the aim of rehabilitation is to give the person their own life back – not some “living by numbers” recipe made up of lists, targets and goals.

Both those posts met with a certain amount of enthusiasm, and an equal degree of push-back. Push-back comes from a sense of certainty that of course exercise is a thing we all should do for our health. Because, of course, our health is the thing we should most value.

Or is it? Health professionals enter their professions for many reasons, but one often unacknowledged one is that we value health. We might not state it in those words, we might couch it in terms of “I want to help people”, “I like to give to my community” or even “I have a calling” (Witter, Wurie, Namakula, Mashange, Chirwa & Alonso-Garbayo, 2018), but during our training, we are encultured into valuing health more highly than, perhaps, we would have.

We are also privileged as health professionals. Witter and colleagues also point out that people become health professionals for financial reasons – job stability, respect, status in a family or community. Some health professionals can train for free, while most will recoup the cost of education during their working life. We are privileged because we have education. We have work. We have respect, mana, so what we say carries weight.

When I consider this construct we call health, I bring to mind the WHO definition which is “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” (Preamble to the Constitution of WHO as adopted by the International Health Conference, New York, 19 June – 22 July 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of WHO, no. 2, p. 100) and entered into force on 7 April 1948. The definition has not been amended since 1948). Health is more than the absence of disease or infirmity. That bears repeating. Health, in tangata whenua terms, is viewed as wellbeing in four areas: taha tinana (physical wellbeing), taha hinengaro (mental wellbeing), taha wairua (spiritual wellbeing) and taha whanau (family wellbeing).

I bring to mind a person I know. Let’s call her Allie. She is five years older than me. She is overweight, smokes tobacco and has COPD. She left school at 14 years old, and has worked in minimum wage jobs her whole working life. She became pregnant at 16 years old, and raised her only child as a single parent. He has had a mixed and disrupted life, spending many years in prison with a methamphetamine addiction and multiple convictions for burglary. He has a 14 year old daughter who now lives with her grandmother, Allie.

Now Allie has seen a lot of health professionals. Almost all of them have talked to her about her smoking. They’ve also talked to her about diet and exercise. None of this talk has helped her kick the smoking habit, and exercise? What of it? As she said to me once, “tell me when I can go exercise after I leave home at 6.00am, go to one job, then get back from the second job at 7.30pm?”

What matters to Allie? He tangata, he tangata, he tangata. The most important thing in the world to her is keeping her grand-daughter safe. Allie has spent countless hours trying to give her grand-daughter the security of a settled home, a place where there are rules and boundaries, and a place where there is warmth, food, a bed to sleep in, and people who care. And she’s done this with minimal support from her son, her grand-daughter’s mother, and the NZ social welfare system.

So as health professionals, when we begin to judge or critique people for not being “compliant”, for not being “motivated”, for failing to go to the gym, for not stopping smoking – we need to stop for a minute. Allie has tried countless times, believe me – but has anyone asked her what she gains from smoking? It’s her stress relief. In the absence of alternatives, it’s her reliable stand-by. The only way we’re likely to influence Allie is if we view her life through her eyes, and work with what she values.

And when we prescribe what we think is Most Important because we think the person in front of us values what we value – we’re speaking from a place of privilege, and through a lens that reflects our own priorities. And we could be completely oblivious to this. Such is the nature of privilege. Let’s take a moment to appreciate that the people we serve want to return to their own lives, valuing what they value, with their own priorities, and their own perspectives. Kia kaha, arohanui.

Witter, S., Wurie, H., Namakula, J., Mashange, W., Chirwa, Y., & Alonso‐Garbayo, A. (2018). Why do people become health workers? A nalysis from life histories in 4 post‐conflict and post‐crisis countries. The International journal of health planning and management, 33(2), 449-459.

Is exercise the new snake oil? or just a dirty word?


If you haven’t heard about the health benefits of exercise in the last 10 years or longer, then you’ve probably been a hermit! Exercise can do all these wonderful things – help you lose weight, reduce heart disease, moderate insulin and blood glucose levels, improve your mental health, and yes! reduce pain and disability when you’re sore. (check this list out)

The claims sound suspiciously similar to the claims made by old snake oil merchants – or the amazing White Cross Electric Vibrator!

Well perhaps there’s a little more research supporting claims for exercise… but are those claims being inflated just a little? When it comes to pain, particularly persistent pain, perhaps so…

But before I launch into some of the problems with exercise research, I have another problem with “exercise” – and that’s the word itself.

According to Wikipedia (and no, it’s not an academic reference!!) “Exercise is any bodily activity that enhances or maintains physical fitness and overall health and wellness.” Winter and Fowler (2009) in an interesting paper looking at definitions of exercise, found that “exercise” and “physical activity” are essentially the same and differ only in terms of motivation/intent, finally arriving at this definition: “A potential disruption to homeostasis by muscle activity that is either exclusively or in combination, concentric, isometric or eccentric.” Whew! Glad we’ve got this sorted.

But given the sticky nature of our minds, and that very few of us are inclined to spend hours debating the technical details, the word “exercise” has picked up quite a few other meanings. For me it conjures up images of sweaty, lycra-clad blokes grunting in front of enormous mirrors while they heave on lumps of metal to the pumping rhythm of loud music (and the eyes that follow my every move). It also raises the spectre of school sports where I was inevitably the last person chosen for any sports team, the last to come in after every run, the person who got hit in the face by the ball, who got her thumb smacked by the hockey stick the week before my piano exams…

I’m not alone in my distaste for “exercise”. Qualitative researchers have often investigated how people with pain view exercise: “I get the comments that “It is not dangerous” and that “you are not going to be worse.” I do not believe it is dangerous … but actually it happens that I become worse after .… I know that the pain will increase. And they … talk to me about pain that is not like my pain.” (Karlsson, Gerdle, Takala, Andersson & Larsson, 2018)

Boutevillain, Dupeyron, Rouch, Riuchard & Coudeyre (2017) in another qualitative study, found that people with low back pain firstly identified that pain intensity interfered “any minimal physical activity, standing still in one spot, is torture” (line 1683); “if my back hurts, I don’t do any activity that’s for sure, I am not going to the garden and do some digging, that is out of the question! I have two children, if I am in pain and they want to play, my back hurts and I can’t play with them. My back hurts I can’t do it. It’s not that I don’t want to it is just that I cannot. I am unable to” (line 29). In turn, motivation for exercise was reduced “I don’t have any desire to exercise. A lack of motivation, even apprehension” (line 390); “there needs to be this spark to get motivated, and I just don’t have it” (line 1335). Along with the lack of perceived benefits for some: “Sometimes I try to exercise and then I’m in pain, looking back had I known it would hurt I would probably not have done it” (line 2037) “It can be harmful, I give you an example: I have a colleague with low back problems, similar to mine, and she loves to take step classes, but each time she exercises too much, she is in pain but continues. I think she should stop, it is quite dangerous for her” (line 378).

A systematic review by Slade, Patel, Underwood and Keating (2014) found that “Individuals were more likely to engage within programs that were fun and had variety than ones that were boring, unchallenging, or onerous because they disrupted daily activities.” They added that “Difficulties with exercise adherence and not seeing benefits of exercise were frequently attributed to lack of time and fit into daily life.” Quotes drawn from the studies included in this review show that lack of confidence, negative experiences at the time, and poor “fit” between the exercises selected and individual preferences influence whether exercise was carried out consistently.

At the same time as these negative views, many participants in qualitative studies report that they use “movement” as a key strategy for their daily management. Whether movement looked like “exercise” as prescribed by PTs or trainers is a little less clear – people use the word “exercise” to mean many different things, hence Karlsson and colleagues (2018) combined the term “physical activity and exercise”.

Now one very important point about exercise, and one that’s rarely mentioned, is how little exercise actually reduces pain – and disability. A systematic review of systematic reviews from the Cochrane collaboration found that most studies included people with mild-to-moderate pain (less than 30/100 on a VAS) but the results showed pain reduction of around 10mm on a 0 – 100mm scale. In terms of physical function, significant improvements were identified but these were small to moderate in size.

And let’s not talk about the quality of those studies! Sadly, methodological problems plague studies into exercise, particularly sample size. Most studies are quite small, which can lead to over-estimating the benefits, while biases associated with randomisation, blinding and attrition rate/drop-outs, adherence and adverse effects.

Before anyone starts getting crabby about this blog post, here are my key points (and why I’ve taken this topic on!):

  1. Over-stating the effects of exercise won’t win you friends. It creates an atmosphere where those who don’t obtain pain reduction can feel pretty badly about it. Let’s be honest that effects on pain reduction and disability are not all that wonderful. There are other reasons to move!
  2. Exercise and physical activity can be done in a myriad of wonderful ways, research studies use what’s measurable and controllable – but chasing a puppy at the beach, dancing the salsa, cycling to work, vacuuming the house, three hours of gardening and walking around the shopping mall are all movement opportunities up for grabs. Don’t resort to boring stuff! Get creative (need help with that? Talk to your occupational therapists!).
  3. The reasons for doing exercise are enormously variable. I move because I love the feeling of my body in rhythm with the music, the wrench of those weeds as they get ripped from my garden, the stretch of my stride as I walk across the park, the ridiculousness of my dog hurtling after a ball… And because I am a total fidget and always have been. Exercise might be “corrective”, to increase cardiovascular fitness, because it’s part of someone’s self-concept, to gain confidence for everyday activities, to beat a record or as part of being a good role model. Whatever the reason, tapping into that is more important than the form of the exercise.
  4. Without some carryover into daily life (unless the exercise is intrinsically pleasurable), exercise is a waste of time. So if you’re not enjoying the 3 sets of 10 you’ve been given (or you’ve prescribed to someone), think about how it might translate into everyday life. It might be time to change the narrative about movement away from repetitive, boring exercises “for the good of your heart/diabetes/back” and towards whatever larger, values-based orientation switches the “on” switch for this person. And if you’re the person – find some movement options that you like. Exercise snacks through the day. Jiggles to the music (boogie down). Gardening. Swimming. Flying a kite. Don’t be limited by what is the current fashion for lycra and sweaty people lifting heavy things with that loud music pumping in the background.

Boutevillain, L., Dupeyron, A., Rouch, C., Richard, E., & Coudeyre, E. (2017). Facilitators and barriers to physical activity in people with chronic low back pain: A qualitative study. PLoS One, 12(7), e0179826. doi: 10.1371/journal.pone.0179826

Edward M. Winter & Neil Fowler (2009) Exercise defined and quantified
according to the Système International d’Unités, Journal of Sports Sciences, 27:5, 447-460, DOI: 10.1080/02640410802658461

Geneen, L. J., Moore, R. A., Clarke, C., Martin, D., Colvin, L. A., & Smith, B. H. (2017). Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews. Cochrane Database Syst Rev, 4, CD011279. doi: 10.1002/14651858.CD011279.pub3

Karlsson, L., Gerdle, B., Takala, E. P., Andersson, G., & Larsson, B. (2018). Experiences and attitudes about physical activity and exercise in patients with chronic pain: a qualitative interview study. J Pain Res, 11, 133-144. doi: 10.2147/JPR.S149826

5 Things I Learned from Lock-down


As New Zealand emerges from the most severe lock-down levels to greater freedom (but still not back to life as usual) I’ve been reflecting on what I’ve learned – no, not a new language, new baking skills, or sudden competence in using R (see here for a great tutorial), but things about myself. Odd though it may seem, I’m leaving lock-down with a sense of wistfulness. You see, the time from the end of March to end of April has been a lovely time for me.

I’m lucky, I have a good job, my work hasn’t changed much (well, a bit), my family are safe, I live close to the beach and a park, and the weather has been kind. It’s autumn in Christchurch, and it’s been mainly fine. The bird life has been flourishing. The foot traffic past my house has been families – Mum, Dad, kids on bikes and in pushchairs. Apart from the occasional drop-kick lighting fireworks or playing the Zombie Apocalypse Siren, and hammering from 7.00am to 11.30pm, our neighbourhood has been peaceful. And yet I know so many people in New Zealand and around the globe who are really struggling. Strange times indeed. So what have I learned?

  1. Solitude is not the same as loneliness. Solitude is being alone and being OK with it. Loneliness is being alone when you don’t want to be. Being with my own thoughts, listening to the murmuring of sounds around me, letting my mind wander then gently bringing it back to focus is a pleasure, almost an indulgence. Having headspace to let what passes through my mind just pass by, without music or talking or anything interrupting my musing is a pleasure. Better still: being with someone who also appreciates being together in silence. I’ve learned to love solitude.
  2. Some kids will remember this time with gratitude. I’ve watched whole families walking together, making huts from driftwood, spotting the teddies in the windows, making low-tech memories of time being together. I have a fairy door (and a fairy) at my gate, and watching the little kids search for the fairy (who flies from tree to tree each day!) is such a joy. I’ve seen Mums and Dads out cycling with their kids then heading home to do the DIY together. What a treasure! I’ve learned (again) that families need time being families.
  3. Some things stay the same – especially if you live with pain. Even though my days have been peaceful, my pain has not. With changes to my routine, the weather, sleep, and world events playing on my mind, my life with fibromyalgia still needs managing. I’ve had aches in places I don’t usually have aches, and the things I do to live alongside my pain still need doing. For me these things are: making sure I carry on with mindfulness (I savour those moments when I can be with my thoughts but not part of them), go for my walk for headspace and body movement, keep my sleep/wake routine reasonably consistent, and eat normally (hah! there’s chocolate and alcohol and crisps. I may have slipped up a little there…). I’ve learned that pain management is really life management.
  4. Comparing myself with others is a waste of time. Yes, there are people out there learning new things, self-improving all over the place, doing their on-line socialising (and CPD), being creative and producing a lot. Good for them! I admire their achievements, and I’ve even contributed to a few of those online Zoom talks. Meanwhile, I thought I’d have been truly productive in the studio making loads of silver jewelry (those of you who don’t know – that’s my ‘hobby’ that seems to have taken over my photography, painting, sewing and everything else!). I’ve created a few pieces – but when I caught myself feeling pressured to come up with a “COVID19 Collection” I realised that this pressure wasn’t me. It was my mind being competitive and wanting to prove something to others. The need to belong can lead me to also want to be acknowledged as Something Special. Better than. As good as. Because, of course, underneath that is “I’m not good enough as I am”. So I decided to let that rope go. I don’t have to compete. There isn’t a prize for She Who Produces The Most because in the end, life is a process not a goal. I’ve learned (again) that comparisons are one way my mind beats up on me, and my mind doesn’t know everything.
  5. Resilient people are adaptable people. Resilience is a word many people in Christchurch, NZ, are well and truly over. Since 2010, and the 10,000 earthquakes since, plus the Port Hills fire, and the terror attack on Al Noor Mosque, people in Christchurch have been challenged more than many in our wee country. Resilience doesn’t mean we’re unchanged. Resilience means we change with circumstances and we develop new ways of being, ways of expressing who we are and what matters to us. I sometimes think people believe resilience means “Oh you’ve bounced back and life goes on as it was” but for me the events since 2010 have had a profound effect on my life. I can’t walk through my city without seeing earthquake-wrought changes. I see bumper stickers saying “they are us” and “kia kaha“. I walk past the memorial wall Oi Manawa when I head in to work. The new streetscapes, city buildings, ongoing roadworks and repairs – all part of the way my city has changed. That underground subversive element in Christchurch has touched so much of our lives. Resilient people have found ways to express who they are despite the enormous impact of events over the past 10 years. I’ve learned that holding on to what I value while finding new ways to express these has given me freedom and growth – but I’ve had to let go of the form, the habitual, the routines that used to frame them. It’s painful. It’s tiring. It’s real and raw and hard work.

How does all this fit into a blog about pain? If pain doesn’t challenge clinicians and people experiencing it, I’ve wasted the last 30-odd years of my clinical career, not to mention my hours of social media involvement!

Change, as a clinician, can be tough – letting go of the form of what we offer (because … science) while holding on to why we ever started working as clinicians requires flexibility.

And solitude – to reflect on what it is we really want. We do it for families, those closest to our hearts (our own families, and others), so people can be who they really are.

Comparing ourselves with others leads to a popularity contest, and the self-management approach to pain is most definitely not a popular meme. I am not part of the Instagram/Twitter/TikTok/whatever meme culture. I don’t do short, snappy sound bites. There are, as far as I can see, no short-cuts or quick fixes for learning to live well with pain. There are only connections between people who care, who are willing to be vulnerable, who will let go of some things in order to take on new things in the pursuit of what matters.

This is what I’ve learned from Lock-down.

Coronavirus (COVID19), catastrophising – and caution


I don’t often leap aboard a popular topic and blog about it, but I’m making an exception right now because, although COVID19 is new – catastrophising is not.

There are a number of people who really do not like the term “catastrophising”. There are comments that this is a pejorative term, used to deny the validity of a person’s experience. That it means the person is exaggerating or being melodramatic or in some way not believable.

But as I read the many, many headlines about COVID19, including the international toilet paper frenzy, reading about Vitamin C or “anti-inflammatory foods” to combat it, I even saw a serious post about using hands-on therapy to “shift the toxins”…. And I wonder whether we can take a good hard look at ourselves and our response to this virus.

Firstly, getting accurate information about COVID19 has been difficult. There are some authoritative sources “out there” but they’re not necessarily the most sexy sites to visit. Not many memes coming out of our Ministry of Health in New Zealand! Much of the information we read on a daily basis is in the general news media, giving a “personal story” slant on “what COVID19 means”. Some really good information coming from our politicians in NZ – but also some scaremongering from the political opposition.

Does this sound familiar? Where does the good, accurate and evidence-based information about persistent pain come from? And in the absence of readily accessible and “memeific” information, where do people go to learn about pain?

Secondly, it’s not the virus itself that’s causing the majority of trouble for people – except for the small percentage for whom the virus is deadly, mainly because of comorbidity, and health vulnerability. People who are older, already have immune compromise, and who are not able to access good healthcare are most at risk. The rest of us are experiencing the fallout of containment measures, economic insecurity, and lack of toilet paper. Sorry, couldn’t resist that last one. Seriously, most of us are being affected by the cancellation of meetings, by the need to self-isolate, by travel restrictions, by people having less money to spend because suddenly their jobs are less secure – watching my savings melt day by day…

Sounds quite similar to the experiences of people with persistent pain: often it’s not the pain itself that’s so awful, but the effects of losing contact with people you love, of having to take medications to reduce pain that leave you feeling dreadful, of not being able to play sports or do work – the loss of income security, access to healthcare, connection with people who matter. These are amongst the most debilitating aspects of living with persistent pain, let along the pain…

If you’ve found it hard to think of anything else but COVID19. If you’ve had trouble taking your mind off how you’re going to get by if patients can’t come to see you because they’re worried about giving you COVID19, or of catching it from you – that’s rumination, or brooding on it.

If you’ve caught yourself heading to the supermarket to get some extra pantry staples “just in case”. If you’ve found yourself checking in to see what your local health authorities are recommending. If you’ve been wondering if you should shut your business down for a while – and then been wondering what you’re going to do for a income if you do that. If you’ve looked up your bank balance and wondered what you’re going to do if your kids are off school for the next month, while you’re meant to be at work and there’s no-one to look after them…. you’re magnifying, or estimating that the demands of this situation might well exceed your current resources to deal with it.

If it all feels a bit overwhelming and you’re not really sure what to do next. If you’re feeling pretty stuck and getting a bit panicky. If this feels just way too much to handle – that’s hopelessness, or feeling really overloaded.

And each of these three clusters of cognitions, emotions and behaviours are part of the catastrophising construct.

Do they feel normal to you? Do you think you’re exaggerating? Do you think your reaction is over the top? No? Well you’d be (generally) quite right (except maybe the toilet paper hoarding… that’s just weird). Thinking the worst is normal in the face of uncertainty. Some commentators and researchers believe it’s one way we learn to convey our need for social support (Bailey, McWilliams & Dick, 2012; Lackner & Gurtman, 2004; Thorn, Keefe & Anderson, 2004).

At the same time, I want to take a pragmatic and contextual look at catastrophising.

From a pragmatic perspective, right now it’s completely appropriate to be a bit discombobulated by COVID19. And many of us have a lot of things to consider over the next few days/weeks as the situation changes on a daily and even hourly basis. The things we’re doing right now to plan for the worst are largely useful. That’s the point of being able to catastrophise – in the right context, in a rapidly evolving health and economic crisis, being able to consider the various futures and put plans in place to deal with them is probably a good thing. That’s the action part of the catastrophising construct.

The difficulty NOT checking your news media feed, and feeling a bit overwhelmed by it all seems to be a fairly reasonable response to an unreasonable situation. Logic, right?

So, from a pragmatic perspective right now, in the face of uncertainty, most of us are doing exactly what has got humans out of trouble many times in our history.

Now, what if we shift the context to 24 months in the future. COVID19 has now been largely contained, a vaccine is available, the virus hasn’t evolved, and while the economy is slowed, it is gradually picking up. What if, at that time, we have a friend who is still nervously scanning the headlines for the latest information on the virus? What if that friend is still stockpiling pasta and toilet paper and hand cleanser? What if that friend is still feeling like there’s not much they can do except hunker down and hide?

Now, my guess is that many of us would think this is being a bit extreme. Maybe even a bit OTT. Especially given that there’s likely to have been a LOT of media coverage of the COVID19 vaccine, and most economic activity will be returning. We might begin suggesting (gently) to the person doing the stockpiling that maybe it’s not necessary to keep on doing so. We’d think it’s a good idea to give them the new information about COVID19. We’d probably suggest that although they’re freaking out, maybe it’s time to reconsider the threat.

Context matters – catastrophising can be useful right now. In 24 months: not so much. New information will likely help us take a more realistic look at what’s going on with COVID19. It’s not that individual people won’t be personally affected if they get sick, but probably the crisis that’s happening right now will be over.

What about the validity of the person’s emotional response to their feared situation? Would we be dismissive? I hope not – because anyone who is still freaking out about COVID19 in 24 months time is still in distress! But we might be more willing to share the good news about recovery with them, so they don’t continue feeling overwhelmed and distressed. We’d not be likely to let them carry on thinking the worst, and we certainly wouldn’t be telling them their response is perfectly valid and appropriate for the threat.

What of the person experiencing pain and thinking the worst, feeling pretty awful and hopeless? Would we support them to stay in that highly distressed state? Would we say “there, there, you’re really feeling bad, aren’t you, here’s a tissue” – and walk away? Would we hesitate to suggest that perhaps they’re magnifying the problem and that they might have some other options?
Think about it. Catastrophising is a well-validated and studied construct. Hundreds of studies have shown that catastrophising is associated with poorer outcomes in so many situations – childbirth, knee replacements, hip replacements, multi-trauma orthopaedics, discomfort during internal atrial cardioversion, length of hospital stay after knee replacement, use of medications – on and on and on.

Catastrophising gets a bad rap. And woe betide anyone who TELLS someone “you’re catastrophising” because you seriously deserve a slap. Sheesh! But take a moment to consider the adverse impact on the person of thinking the worst… sleepless nights, endlessly checking their body, feeling overwhelmed and overloaded, having trouble thinking of anything else, perhaps anxious and depressed… this is not a recipe for recovery.

Call it what you will – over-estimating the threat of something, and under-estimating your resources can act as a galvaniser for preparation and action in the short term and in the context of uncertainty. When there are ways to move forward, and the threat is maybe not so great as you thought, and maybe you can do something to help yourself – then it’s probably time for us to show strong compassion. That’s compassion that cares enough to have difficult conversations, that helps another person consider their response in light of new information, and is willing to be there to help the person re-evaluate their next best steps.

Keep safe. Keep your social distance. Wash your hands. Don’t go out if you’re sick. Be sensible with the toilet paper.

Bailey, S. J., McWilliams, L. A., & Dick, B. D. (2012). Expanding the social communication model of pain: are adult attachment characteristics associated with observers’ pain-related evaluations? Rehabil Psychol, 57(1), 27-34. doi: 10.1037/a0026237

Lackner, Jeffrey M., & Gurtman, Michael B. (2004). Pain catastrophizing and interpersonal problems: a circumplex analysis of the communal coping model. Pain, 110(3), 597-604. doi: 10.1016/j.pain.2004.04.011

Thorn, Beverly E., Keefe, Francis J., & Anderson, Timothy. (2004). The communal coping model and interpersonal context: Problems or process? Pain, 110(3), 505-507.