Therapeutic approaches

Conversations about cannabis for chronic pain


The debate about cannabis and derivatives for persistent pain continues to grow in New Zealand, and elsewhere in the world. Many people I’ve treated and who are living with persistent pain say they like to use cannabis (in a variety of forms) to help with pain intensity and sleep, adding their voices to those wanting “medicinal” cannabis to be approved. In the few patients I’ve worked with who have managed to obtain a cannabis product (in NZ it has to be legally prescribed and will generally be in the form of Sativex or similar) the effect doesn’t seem as profound as the real thing (whether smoked, vaped, or in edibles).

Here’s my current position, for what it’s worth. Right now I think cannabis legislation needs an overhaul. Cannabis doesn’t seem to fit into the same class as synthetic drugs (often called “herbal highs” or synthetic “cannabis”) – for one, the plant probably contains a whole lot of substances that have yet to be fully analysed, and for another, I have yet to see a death reported from cannabis use, yet in Auckland, NZ, alone this year there have been around 9 people who have died from taking the synthetic substance, whatever it is. Cannabis seems to cause less harm than legal substances like alcohol and tobacco, and in many places in the world it’s been legalised with some interesting effects on use of opioids.

Ever since Professor David Nutt visited New Zealand a few years back, I’ve been convinced it’s time for a rethink on cannabis laws, but at the same time I’m not ready to support wholesale legalisation of “medical” marijuana. Here are a few reasons why:

  • When a doctor prescribes a drug, he or she is able to rely on the manufacturer making a consistent product, with a consistent amount of “active” ingredients, and a consistent quality. At present, with the exception of the two versions available in New Zealand, this can’t be guaranteed. Plants vary in the combination of active chemicals in them, and storage and age of the product influence the availability of those chemicals when inhaled or ingested. Just as we don’t suggest people go and grow their own opium poppies because we know that opioids are effective analgesics, I don’t think it’s time to allow people to grow their own cannabis for medicinal purposes, such as treating pain. A doctor can’t know just how much of a dose a person can get because in NZ we don’t yet have a controlled environment for cannabis production.
  • When a doctor prescribes a drug, he or she is also guided by the indications for use. So, although some medical practitioners prescribe “off-label” use for medications (a good example is nortriptyline, an antidepressant used often for pain reduction), generally there are good double-blinded, randomised controlled trials to determine whether the active drug is more effective than placebo. When we read about cannabis use for medicinal reasons we hear of its use for cancer (mainly nausea, but also pain), neuropathic pain, and in the general media we hear of its use for migraine, period pain, abdominal pain, fibromyalgia, osteoarthritis – there’s very few pain disorders that cannabis isn’t seen to be appropriate. But the truth is, we don’t really know which kind of pain (the underlying mechanism) will respond, and what pains don’t respond. It’s still a bit of a mystery – mind you, this is not any different from other medications for pain for which N=1 seems to be the mantra.

Why might I support a change to marijuana laws?

Well, an interesting study from the Northeastern United States, and published in the journal Pain, looked at the perspectives of people enrolled in legal medical marijuana clinics. It was quite a large study of 984 people, so should represent a good cross-section of those using the drug within a legal system. Participants were asked to complete an online survey, and their responses were analysed by a psychologist who was “not a cannabinoid expert”, arranging the data into themes and subthemes. (As an aside, apparently this was carried out using a “Grounded Theory perspective” based on Corbin and Strauss – BUT essentially the researchers didn’t follow grounded theory methodology throughout, and instead it should be called a thematic analysis using inductive coding. Pedant, yes!). The data was then examined to quantify the responses (another violation of GT methodology), and re-examined by another co-author for verification.

What they found was a group of people, over half women, with 2/3 indicating they’d been diagnosed with chronic pain by a medical professional. Diagnoses varied, but most (91%) had low back and neck pain, 30% with neuropathic pain, 23% with postsurgical pain, nearly 22% with abdominal pain, 20% with chronic pain after trauma/injury, 7% with cancer pain and 5% with menstrual pain.  Most people smoked cannabis either by joint, pipe or bong; some used a vaporiser, some had edibles or a tincture, and least, some sort of ointment.

The participants indicated it was on average 75% effective at reducing/treating symptoms, which is extraordinary when you realise that traditional forms of medication for neuropathic pain may reduce pain by 50% in around 1  in 4 people (Woolf, 2010). Participants spent around $3118 each year, but this was skewed because concentrates cost $3910, while topicals were $814. Joints were more expensive than vaporised product ($260 different!).

Analysing the positives of cannabis, participants reported pain relief, or at least being able to tolerate the pain more easily; while sleep benefits was the next most significant theme. Participants were encouraged that cannabis doesn’t have overdose potential, it’s natural, there are a wide range of strains with different characteristics, and limited potential for dependence.

There were numerous other positive aspects to using cannabis this way, according to the participants: things like “feeling normal”, “I am more active and able to do things I want”, being “distracted” from the pain, “able to focus”, and “able to relax”.

Negative perspectives included the cost (too expensive – in NZ Sativex is around $1000 a month – not covered by NZ pharmaceutical subsidies); some people didn’t like the smell, the effects on lungs and breathing, appetite changes (and gaining weight), and some emotional effects like anxiety or paranoia. Stigma and judgement by others also features, as did the difficulty accessing the drug, and conflict about the different laws applying to cannabis use – noting that the US has different federal and state laws.

Overall, the responses from these participants suggest a benign, mainly positive response to a drug, with negatives primarily around the social aspects – stigma from health providers, other people thinking of the participants as stoners, the legal situation and so on. For me, the limitations of this study really preclude any major judgement as to benefit or otherwise. We only know what this group of people believed, they have a vested interest in promoting benefits because negatives won’t support their belief that this is a viable treatment option, we don’t know the effect on function (particularly objective data), and we have no way of verifying the diagnoses individuals reported as the reason for prescription.

My conclusion?

It’s way past time to discuss cannabis use, health risks and health benefits. To have an open discussion about use for medicinal reasons, we need to remove the current barrier: the legal situation. While people have a vested interest in promoting the benefits over risks or adverse effects, we’re not going to have a very clear picture of what happens with ongoing use. I don’t support the use of cannabis as a medicinal product – to me there are far too many unknowns, and I think we risk wedging open a gate that has, until now, been useful for limiting the risk from pharmaceutical harms. We need to subject cannabis to the same level of rigour as any other pharmaceutical product being introduced to the market.

On the other hand, I think removing legal barriers to recreational use is about balancing the benefits and harms of this substance against other substances used for similar reasons. Alcohol and tobacco are well-known for harmful effects. Prohibition of alcohol did not work. Tobacco smoking is reducing over time courtesy of a committed campaign documenting harms, as well as raising the price via taxation. We can’t campaign around health harms for a product that isn’t legal. We can’t establish useful regulation over who produces it, who can buy it, where it can be used, the effects on work injury/vehicle injury, we can’t represent the undoubted benefits, and we look, to many people, to hold a double-standard.

And sneaking cannabis use in under the guise of “medicinal” use just isn’t on, in my humble opinion. Let’s not put medical practitioners in an unenviable situation where they’re asked to prescribe a product that is not yet examined to the level we expect for every other pharmaceutical product on the market. Let’s spend some precious research funding to establish WHO cannabis helps, WHAT it helps with, and HOW it helps – and most importantly, let’s look at whether it helps produce outcomes that surpass other approaches to persistent pain. We need to face it, currently our treatments are not very good.

 

Piper, B. J., Beals, M. L., Abess, A. T., Nichols, S. D., Martin, M. W., Cobb, C. M., & DeKeuster, R. M. (2017). Chronic pain patients’ perspectives of medical cannabis. Pain, 158(7), 1373-1379.

Woolf, C: (2010). Review: Overcoming obstacles to developing new analgesics, Nature Medicine (Supplement); 16,11: 1241 – 47

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Returning to work, good or bad?- a very complex question


One of the main reasons returning to work is a priority in many healthcare systems is simply that compensation and off-work benefits is the most costly portion of the bill for people with ill health. This naturally leads to a strong emphasis in most rehabilitation, especially musculoskeletal rehabilitation in New Zealand, to help people return to work as soon as practicable. At times the process can be brutal. In my own case, after 18 months of working part-time due to post-concussion symptoms after a “mild” traumatic brain injury, I had the hard word put on me to get back to my job or I’d be sent to work back on the wards (after having spent most of my clinical career working in pain management). Not quite the supportive approach I needed when I was having to sleep for at least an hour every afternoon!

I can well remember the pressure of trying to maintain my work output to the satisfaction of my manager, keep my home responsibilities going (I had teenaged children at the time), manage all the paperwork required just to be part of a rehabilitation system, maintain my relationship which was strained just because I had no energy to play or have fun the way I used to. Oh and I had weekly rehabilitation appointments to top it all off! Not easy to keep your cool when everything seems balanced on a knife-edge.

Yet, despite the challenges of going back to work, most accounts of recovery from musculoskeletal pain find that returning to work forms a crucial element in maintaining long-term gains. The study that sparked this post is a good example: Michael Sullivan and colleagues, set in Montreal, Canada, found that returning to work helps to maintain treatment gains in people with whiplash injury. Of the 110 people enrolled in this study, 73 participants returned to work by the end of one year, while the remaining 37 remained off work. Using regression analysis, the researchers found that the relationship  between return to work and maintaining treatment goals remained significant even when confounds such as pain severity, reduced range of movement, depression and thinking the worst (catastrophising) were controlled. What this means is that something about those who returned to work seemed to help them achieve this, and it wasn’t the usual suspects of low mood or that the injury was more severe. What is even more striking is that those who didn’t return to work actually reported worsening symptoms.

There are plenty of arguments against this finding: could it be that those who didn’t return to work just didn’t respond as well to the treatment in the first place? Well – the authors argue no, because they controlled for the things that should have responded to treatment (eg range of movement, mood). Participants in the study returned to work 2 months on average after completing their treatment, and final measurement was on average 10 months later suggesting that it was something to do with being at work that made a difference.

In their discussion, the authors suggest that perhaps those who didn’t return to work were overall less physically active than those who did, compromising their recovery potential. They also note that being out of work is known to be associated with poorer mental health, so perhaps that explains the difference at the end of the trial period. In addition, they point out that perhaps ongoing stress related to having to handle disability claims processes, perhaps even the financial stress of being unable to work might have been influential.

It’s this last point that I think is interesting. There is no doubt that people who encounter the disability systems that fund their treatment and replace their income feel like their autonomy and independence has gone. They feel their world is being manipulated at the whim of case managers, treatment providers, assessing doctors, and even their family.  A sense of injustice can be detrimental to outcomes for people with whiplash, as Sullivan and colleagues showed some years ago (Sullivan, Thibault, Simmonds, Milioto et al 2009), and we know also that social judgements made about people who experience persistent pain are often negative and exert an influence on the experience of pain itself (Bliss, 2016; Schneider et al, 2016).

Working is really important to people – even in a job you don’t especially enjoy, there are important reasons you keep going (even if it’s only for the money! Money in the hand means food for you and yours, power for the lighting and heating, and even a little bit left over for jam on your bread!). In addition to the money, the most commonly asked question when you’re introduced to someone is “and what do you do for a job?” It’s a way of categorising a person, as much as we hate that idea. Work gives us social contact, routine, purpose and allows us a way to demonstrate competence. Without the anchor of working, many people who live with persistent pain feel the burden of social judgement “who are you?”, of ongoing bureaucracy (filling in paperwork), of repeated assessments to justify not being at work, of constantly being asked to attend appointments, of never feeling like time is their own. Balancing the demands of a system that judges you negatively because you are “unfit” against the demands of family and your own needs is an incredibly difficult process – but then again, so is the process of returning to a job where you fear you’ll fail and experience That Pain Again, and where, if you fail, you could lose that job entirely.

I don’t have an answer to how we can make this process easier. I do know that early return to work can be positive if handled well – but handled poorly, can be an extremely unpleasant and stressful process. Vocational rehabilitation providers need to understand both acute and persistent pain. They also need to carefully assess the psychosocial aspects of a job, not just the biomechanical demands. And someone needs to represent the needs of the person living with persistent pain and help them balance these demands carefully.

 

Bliss, Tim VP, et al. (2016)”Synaptic plasticity in the anterior cingulate cortex in acute and chronic pain.” Nature Reviews Neuroscience .

De Ruddere, Lies, et al. (2016)”Patients are socially excluded when their pain has no medical explanation.” The Journal of Pain 17.9 : 1028-1035.

McParland, J. L., & Eccleston, C. (2013). “It’s not fair”: Social justice appraisals in the context of chronic pain. Current Directions in Psychological Science, 22(6), 484-489.

Schneider, Peggy, et al. “Adolescent social rejection alters pain processing in a CB1 receptor dependent manner.” European Neuropsychopharmacology 26.7 (2016): 1201-1212.

Sullivan, M. J., Thibault, P., Simmonds, M. J., Milioto, M., Cantin, A. P., Velly, A. M., . . . Velly, A. M. (2009). Pain, perceived injustice and the persistence of post-traumatic stress symptoms during the course of rehabilitation for whiplash injuries. Pain, 145(3), 325-331.

Sullivan, M., Adams, H., Thibault, P., Moore, E., Carriere, J. S., & Larivière, C. (2017). Return to work helps maintain treatment gains in the rehabilitation of whiplash injury. Pain, 158(5), 980-987. doi:10.1097/j.pain.0000000000000871

Mulling over the pain management vs pain reduction divide


I’ve worked in persistent pain management for most of my career. This means I am biased towards pain management. At times this creates tension when I begin talking to clinicians who work in acute or subacute musculoskeletal pain, because they wonder whether what I talk about is relevant to them. After all, why would someone need to know about ongoing management when hopefully their pain will completely go?

I have sympathy for this position – for many people, a bout of tendonosis, or a strained muscle or even radicular pain can ebb away, leaving the person feeling as good as new. While it might take a few months for these pain problems to settle, in many instances there’s not too much need for long-term changes in how the person lives their life.

On the other hand, there are many, many people who either don’t have simple musculoskeletal problems (ie they’re complicated by other health conditions, or they have concurrent issues that make dealing with pain a bit of a challenge), or they have conditions that simply do not resolve. Good examples of these include osteoarthritis (hip, knee, shoulder, thumbs, fingers) and grumbly old lower back pain, or peripheral neuropathy (diabetic or otherwise). In these cases the potential for pain to carry on is very present, and I sometimes wonder how well we are set up to help them.

Let’s take the case of osteoarthritis. Because our overall population is aging, and because of, perhaps, obesity and inactivity, osteoarthritis of the knee is becoming a problem. People can develop OA knee early in their life after sustaining trauma to the knee (those rugby tackles, falling off motorcycles, falling off horses, running injuries), or later in life as they age – so OA knee is a problem of middle to later age. People living with knee OA describe being concerned about pain, especially pain that goes on after they’ve stopped activities; they’re worried about walking, bending and maintaining independence – and are kinda pessimistic about the future thinking that  “in 10 years their health would be worse and their arthritis would be a major problem” (Burks, 2002).

To someone living with osteoarthritis, especially knee osteoarthritis, it can seem that there is only one solution: get a knee replacement. People are told that knee replacements are a good thing, but also warned that knee replacements shouldn’t be done “too soon”, leaving them feeling a bit stranded (Demierre, Castelao & Piot-Ziegler, 2011). Conversations about osteoarthritis are not prioritised in healthcare consultations – in part because people with knee osteoarthritis believe that knee pain is “just part of normal aging”, that there’s little to be done about it, and medications are thought to be unpleasant and not especially helpful (Jinks, Ong & Richardson, 2007).

I wonder how many healthcare professionals feel the same as the participants in the studies I’ve cited above. Do we think that knee OA is just something to “live with” because the problem is just part of old age, there’s an eventual solution, and meanwhile there’s not a lot we can do about it?

When I think about our approach to managing the pain of osteoarthritis, I also wonder about our approach to other pains that don’t settle the way we think they should. Is part of our reluctance to talk about pain that persists because we don’t feel we know enough to help? Or that we feel we’ve failed? Or that it’s just part of life and people should just get on with it? Is it about our feelings of powerlessness?

In the flush of enthusiasm for explaining the mechanisms of pain neurobiology, have we become somewhat insensitive to what it feels like to be on the receiving end when the “education” doesn’t reduce pain? And what do we do when our efforts to reduce pain fail to produce the kind of results we hope for? And the critical point, when do we begin talking about adapting to living well alongside pain?

What does a conversation about learning to adapt to pain look like – or do we just quietly let the person stop coming to see us once we establish their pain isn’t subsiding? I rather fancy it might be the latter.

Here’s a couple of thoughts about how we might broach the subject of learning to live with persistent pain rather than focusing exclusively on reducing pain:

  • “What would you be doing if pain was less of a problem?” My old standby because in talking about this I can begin to see underlying values and valued activities that I can help the person look at starting, albeit maybe doing them differently.
  • “What do you think are the chances of this pain completely going away?” Some might say this is about expectancy and I’m setting up a “nocebic” effect, but I argue that understanding the person’s own perspective is helpful. And sometimes, when a person has persistent pain and a diagnosis like osteoarthritis, their appraisal is less about catastrophising and more about holding a realistic view about their own body. It’s not about the appraisal – it’s about what we do about this. And we can use this perspective to built confidence and increase the importance of learning coping strategies.
  • “If I could show you some ways to deal with pain fluctuations, would you be interested in learning more?” All episodes of pain that persists will have times when pain is more intense than others – flare-ups are a normal part of recovering from, and living with persistent pain. Everyone needs to know some ways of going with, being flexible about or coping with flare-ups. I teach people not to focus exclusively on reducing pain during these flare-up periods. This is because even during rehabilitation we don’t want to use pain as a guide (it can be a cruel task-master). We know that rehabilitation can increase (temporarily) pain while the body habituates to new movement patterns, the brain gets used to new input, and the homunculus gets redefined. It’s great to be able to teach strategies that increase the sense of safety, security and down-regulation that can be lost in the initial onslaught of pain.

To summarise, not all pain problems settle. We can help everyone to be more resilient if we begin talking about ways of coping with flare-ups even during subacute pain, particularly if we avoid an excessive focus on trying to avoid them. Instead, we can begin to help people feel confident that flare-ups always settle down, and that they can manage them effectively by using effective self management.

 

Burks, K. (2002). Health concerns of men with osteoarthritis of the knee. Orthopaedic Nursing, 21(4), 28-34.

Cohen, E., & Lee, Y. C. (2015). A mechanism-based approach to the management of osteoarthritis pain. Current Osteoporosis Reports, 13(6), 399-406.

Demierre, M., Castelao, E., & Piot-Ziegler, C. (2011). The long and painful path towards arthroplasty: A qualitative study. J Health Psychol, 16(4), 549-560. doi:10.1177/1359105310385365

Jinks, C., Ong, B. N., & Richardson, J. (2007). A mixed methods study to investigate needs assessment for knee pain and disability: Population and individual perspectives. BMC Musculoskeletal Disorders, 8, 59.

…and now what we’ve all been waiting for: What do to about central sensitisation in the clinic


For the last couple of weeks I’ve posted about central sensitisation; what it is, and how to assess for it. Today I’m going to turn to the “so what” question, and talk about what this might mean when we’re in the clinic.  Remember that most of this material comes from Jo Nijs’ recent talks at the New Zealand Pain Society.
Firstly, remember that pain is an experience that people have, underpinned by neurobiology, but also, depending on the level of analysis, on interactions with others, on systems and how they work, on culture, on individual experiences, and of course, on interacting within a body within an environment or context. Everything I say from here on is based on these assumptions.

The first point Jo Nijs makes is that when we know a bit more about the neurobiology of persistent pain associated with central sensitisation, we can use this knowledge wisely when we help someone make sense of their pain. This doesn’t mean wholesale and broadcast “I-will-tell-you-all-I-know-about-pain-neurobiology-because-I-know-you-need-to-know-it-because-I-know-it-and-think-it’s-important” which is, truth to tell, a lot more about the know-it-all than the person in front of them! We need to earn the right to give information – that means establishing that we’ve heard the other person’s story and the current meanings they’ve made from their experience. It also means asking permission to share new information. It means thinking about WHY we want to share new information.

So what if the person doesn’t use the same groovy language we use to describe his or her understanding?! So what if they’ve got some of the newer ideas slightly skewed. In the end, what’s important is that the person understands these things:

  • Pain isn’t a direct reflection of what’s happening in the tissues.
  • Pain can be influenced by many things, some of which are physical forces (heat, pressure and so forth), some of which are ideas, and some are emotions. And there are a bunch of other variables that can influence the experience, including what else is going on around the person.
  • The brain is intimately involved with our experience of pain, and it’s a two-way street from body to brain and brain to body.
  • Persistent pain is more about neurobiology than tissue damage per se (but not exclusively about neurobiology).

Our job is to make sure the person understands these things, rather than our job being about “educating” people. The end result matters, rather than any particular process.

If we look at the evidence for helping people reconceptualise their pain, there’s plenty to show that this approach is useful – it’s been a key tenet of a self-management cognitive behavioural approach to pain management since at least the late 1970’s. The later research (from Butler, Moseley and Louw et al) is simply looking at this approach within a slightly different cohort and in a different context. Rather than being integrated with an interdisciplinary pain management programme, research from these guys shows that physiotherapists (in particular) can deliver this kind of information very effectively – and that it helps reduce the fear and subsequent efforts to avoid pain (such as not moving, seeking healthcare, and being worried about pain). Yay!

It’s true that there are many different ways to influence the descending modulatory system, and release endorphins. One of them is to help people understand their pain and be more confident about moving. Another is to place hands on the person – hence massage therapy, manual therapies, manipulations and so on. Nijs believes hands on therapy has best effect after you’ve gone through some of the reconceptualisation that’s often needed (Bishop, Torres-Cueco, Gay, Lluch-Girbes, Beneciuk, & Bialosky, 2015).

Similar arguments can be made for considering sleep management and stress management as an integral part of pain management. (To be perfectly honest, I always thought this was part of what we did…). So here’s the argument: we know most people with persistent pain experience rotten sleep. We also know that people are stressed by their experience of pain. Because poor sleep is associated with increased activation of glia in the prefrontal cortex, amygdala and hippocampus, and therefore are pro-inflammatory, pain is often increased after a poor night’s sleep. Sleep medications interfere with the sleep architecture, so it’s useful to consider nonpharmacological approaches to sleep management.

Three strategies to consider:

  • CBT for insomnia – here’s one resource to use
  • ACT or acceptance and commitment therapy – I’ve written a great deal about ACT, just use the search function on this blog for more
  • Exercise – OMG yes, exercise is effective! (just not right before bedtime, kthx)

Stress management is tougher. We can’t avoid experiencing stress – and neither can we live in a bubble where we don’t ever get exposed to stress. Instead, we probably all could do with learning multiple ways of managing stress. Things like realistic evaluations of the situation, increasing our capabilities for regulating our response to stress via biofeedback if need be, and using mindfulness as a strategy for being with stress instead of fighting against it, or folding beneath it.

I haven’t cited many references in this post – not because there aren’t many, but because there are SO many! And I’ll post more next week when I start looking at the rather sexy neurobiological examinations of processes used in pain management for years (yes, we’ve been doing it for a long time, we now have great explanations for how these things might work – though effect sizes are still small.)

 

Bishop, M. D., Torres-Cueco, R., Gay, C. W., Lluch-Girbés, E., Beneciuk, J. M., & Bialosky, J. E. (2015). What effect can manual therapy have on a patient’s pain experience?. Pain, 5(6), 455-464.

 

… a little more about Pain Catastrophising subscales


I’ve been writing about the Pain Catastrophising Scale and how to use this instrument in clinical practice these last two posts here and here because the construct of catastrophising (thinking the worst) has become one of the most useful to help identify people who may have more distress and disability when dealing with pain. Today I want to continue with this discussion, but looking this time at a large new study where the subscales magnification, rumination and hopelessness have been examined separately to understand their individual impact on pain severity and disability.

Craner, Gilliam and Sperry looked at the results of 844 patients with chronic pain prior to taking part in a group programme (a heterogeous sample, rather than a single diagnosis, so this group probably look at lot like those admitted to high intensity tertiary chronic pain management services such as Burwood Pain Management Centre here in Christchurch).  Most of the participants were female, European/white and married, and had chronic pain for an average of 10.7 years. Just over half were using opioid medication to manage their pain.

Along with the PCS, participants also completed some very common measures of disability (Westhaven-Yale Multidimensional Pain Inventory – MPI) and quality of life (SF-36), and the CES-D which is a measure of depression.

Now here comes some statistical analysis: multiple hierarchical regression! Age, sex, duration of pain and use of opioids were entered into the equation and found to account for only 2.0% variance of the pain severity subscale of the MPI – but once the PCS was added in (subscales entered separately) an additional 14% of the variance was accounted for, but the helplessness subscale was the only one to contribute significantly to the overall variance.

When Pain Interference was  entered as the dependent variable, all the same demographic variables as above contributed a meagre 1.2% of the variance, but when the Pain Severity subscale scores were added, 25.5% of the variance was explained – while the combined PCS subscales contributed 6.5% of the variance. Again, helplessness was the only subscale to contribute to Pain Interference.

Moving to quality of life – the physical subscale of the SF-36 was used as the dependent variable, and once again the demographic variables accounted for only 1.5% variance in physical QOL, with Pain Severity accounting for 23%. PCS subscales contributed only 2.6% of the variance, with only the magnification subscale being identified as a unique contributor. When the mental health subscale was used, again demographics only accounted for 1.2% of variance, with pain severity accounting for 12.4% of the variance. This time, however, the PCS subscales contributed 19.5% of the variance with both Magnification and Helplessness contributing to the variance.

Finally, examining depression, demographics contributed a small amount of variance (3.3%), with pain severity additing 9.8% of variance. The PCS subscales were then entered and contributed a total of 21% to the prediction of depression with both Magnification and Helplessness contributing to the overall depression variance.

The so what factor

What does this actually mean in clinical practice? Well first of all this is a large group of patients, so we can draw some conclusions from the calculations – but we need to be a little cautious because these participants are a group who have managed to get into a tertiary pain management facility. They’re also a group with a large percentage using opioids, and they were pretty much all European – and from North America, not New Zealand. I’m not sure they look like the people who might commonly come into a community-based facility, or one where they’d be referred directly from a GP or primary care centre.

At the same time, while this group may not look like the people most commonly seen for pain management, they share some similar characteristics – they tend to magnify the “awfulness” of pain, and then feel helpless when their pain is bothering them. Surprisingly, I thought, ruminating or brooding on pain wasn’t a unique contributor and instead the helplessness scale contributed the most to pain severity, pain-related interference (disability associated with pain), poor mental health quality of life, and low mood, while magnification scale contributed to poorer physical health quality of life, mental health quality of life and low mood.

What this means for practice

The authors suggest that the construct measured by the helplessness subscale might be a factor underlying poor adaptation to life’s difficulties in general, leading to passivity and negative emotions. They also suggest that magnification might be a unique contributor to perceiving obstacles to doing the things we need to do every day, while hopelessness might mean people are less likely to participate in enjoyable activities and then in turn contribute to feeling low.

Importantly, the authors state: “We offer that simply collapsing the 3 dimensions of this phenomenon (ie, rumination, magnification, helplessness) may actually conceal nuanced relationships between specific dimensions of catastrophizing and outcomes that would might inform treatment approaches.” Looking at the overall scores without thinking about the subscales is going to give you less information to use for individualising your treatment.

In a clinical setting I’d be reviewing the individual subscales of the PCS alongside both disability and mood measures to see if the suggested relationships exist in the scores this person has given.

I’d be taking a look at the repertoire of coping strategies the person can identify – and more, I’d be looking at how flexibly they apply these strategies. Extending the range of strategies a person can use, and problem-solving ways to use these strategies in different activities and contexts is an important part of therapy, particularly occupational therapy and physiotherapy. Another approach you might consider is helping people return to enjoyable activities that are within their tolerance right here, right now. By building confidence that it’s possible to return to things that are fun we might counter the effects of helplessness, and help put pain back where it belongs – an experience that we can choose to respond to, or not.

I’d also be taking a look at their tendency to avoid feeling what their pain feels like, in other words I’d like to see if the person can mindfully and without judging, complete a body scan that includes the areas that are painful. This approach is intended to help people notice that alongside the painful areas are other nonpainful ones, and that they can successfully be with their pain and make room for their pain rather than attempting to block it out, or over-attend to it. The way mindfulness might work is by allowing people to experience the sensations without the judgement that the experience is bad, or indicates some terrible catastrophe. It allows people to step back from the immediate reaction “OMG that’s BAD” and to instead take time to view it as it actually is, without the emotional halo around it.

Pain catastrophising is a useful construct – but I think we need to become more nuanced in how we use the scores from the questionnaire.

Craner, J. R., Gilliam, W. P., & Sperry, J. A. (2016). Rumination, magnification, and helplessness: How do different aspects of pain catastrophizing relate to pain severity and functioning? Clinical Journal of Pain, 32(12), 1028-1035.

Ups and downs and rocking and rolling


What a week it has been! Not only an unexpected result in the US elections, but also a very large earthquake north of Christchurch, along with a tsunami alert for the entire eastern coastline of New Zealand. Luckily I live far enough away from the shoreline that I didn’t have to evacuate, but the sirens certainly work!

As a result of these events, which I firmly believe are NOT associated except in time, the post I was going to make seems a bit redundant, so I’m going to talk about resilience and what it really means.

For someone who has lived through thousands of earthquakes since September 2010, resilience is almost a dirty word. People living in Christchurch are a bit tired of being called resilient.  You see, it’s not the quakes that are the problem – it’s the aftermath. The “new normal” that we’ve been living through these past years. The thousands of road cones lining almost every street. The constant detours as bits of road are dug up and sewerage, storm water and water pipes relaid. The delays. The ongoing processing needed to work out “where am I?” in the streets we used to know so well.

Resilience is intended to refer to “bounce back”. The thing is, I don’t think we bounce back to exactly the way we were before – we’re irrevocably changed by all experiences, but especially ones as significant as the earthquakes, or even political changes. That we don’t “return to normal” is one of the main reasons I don’t believe reports of people “going back to normal” if pain is completely removed. Why? Because people actively process and make meaning from everything that happens to them – and the meanings that are given to experiences don’t ever completely go.  We know, for example, that we can’t “unwire” nerves that have fired together, so what actually happens is that alternative paths or connections between nerves are formed. This means that under the right circumstances, those original paths will fire again… And people who have experienced chronic pain will, even if their pain eventually goes, know exactly what that pain meant, how it affected them, and I’m certain will be very aware of any new pain that seems to be similar to the one that was just there.

Resilience to me is therefore not so much about “bouncing back” as it is about being able to take stock of what actually IS, determine the paths that lead on in the direction of important values, and then choosing to take those paths. And this can often mean taking detours because old paths aren’t negotiable any more. That can be, and is, disturbing. It can be frustrating, fatiguing and far more demanding than the idea usually invoked by the word “resilience”.

So, in the next days and weeks, let’s think less about being resilient, and more about being flexible – flexibly persisting, if you will. We need to persist to get anywhere, do anything. We need to be flexible about how we get there and how we do what we value. We’ll need passion, but more than passion, we’ll need commitment.

 

Clinical reasoning “think aloud”


Occupational therapists are keen on helping people return to doing the things they value – meaningful activity, or participating in valued occupations (same thing, essentially). So, a person might come to see me because they have low back pain and want to work out how to get to work.

My first step is to understand what it is about the back pain that seems to be stopping the person from doing the tasks involved in their work. I usually begin by taking a history – what does the person understand about how their back pain came on, what’s their theory as to why it’s there, what have they done to help their recovery, how are they managing the everyday things they need to do right now. I ask about sleep, sex, personal care, daily routine, and in doing so I’m finding out about the person’s beliefs and attitudes towards their pain, their ability to regulate their arousal level, their mood, their confidence, the influence of others around them (both supportive – and those more subtle influences like their response when the person does something). I’m very careful to try to understand the contexts in which the person is having trouble – and what factors in the context might be supporting change.

In my mind I’m trying to establish a set of possible reasons for this person coming to see me at this time and in this way. I’m running through the various influences I know affect a person’s ability to engage in normal daily activities. Because I have a strong psychology background, I’ll consider functional behavioural analysis, but I’m also sensitive to personal values, cultural norms, and yes, even biological factors such as strength, range of movement, and motor control.

I can try to influence two things: the demands of the tasks in the context of work, and the capabilities of the person, but I need to keep a couple of things in mind.

  1. What is the effect of my intervention in the medium to long-term, not just the short-term?
  2. What does this person need in this context right now?

Depending on my clinical formulation, and the overall theoretical model I’m using, I can approach the decision-making in many different ways. As you’ve probably guessed, I’m a fan of Acceptance and Commitment Therapy, so my end goal is to help this person develop the ability to respond flexibly to the demands of any situation. I want to keep in mind that what I do now can have a long-term influence on what they’ll do over time. Some occupational therapists may instead focus primarily on “what will solve the problem for this person right now” without always thinking about the long-term impact.  As a result, we can see some people with low back pain being given special seating, perhaps a new bed, some adaptive equipment so they can achieve the goal of “doing” – but at the same time, being unaware of the constraints this can put on the person being able to participate in other contexts.

For example, if my client is having trouble getting to work because he thinks his car’s seat should be fixed. If my focus was purely on helping him drive his car in comfort, I could consider assessing his car and giving him some cushioning to make it more supportive. There, problem fixed! But, let’s take a look at the effect of that intervention in the medium term. While he can drive to and from work, he’s learned that he “needs” a special seat or cushioning to help stop his discomfort. He’s also learned that his back pain is something he “shouldn’t” experience.

Based on what he’s learned from my intervention, what do you think can happen if he continues to experience back pain in the work setting?

His personal model of pain will have developed a couple of interesting quirks (and ones we often see in clients) – he’s learned that posture influences his back pain, and that there is a posture that “fixes” it. He’s learned that he should have his back in a particular position to be comfortable. He’s also learned that because he can influence his sitting position in the car, he “should” be able to influence his sitting position in other contexts – like, perhaps, his office desk or the seat in his digger. He might even, if his belief that his back “should” be in a particular position is especially strong, begin to try to keep his back in this position while doing other activities like walking or carrying things, or using tools. Most insidiously, he has learned that his back pain is something he should not have. It’s a sign to him that he has to “fix” his sitting position or he’s doing something wrong. But back pain is common, many factors influence it, and it often doesn’t settle completely.

If I instead want him to be able to respond flexibly to many different settings, I’ll need to think more carefully about my intervention. My underlying reasoning has to capture the workability of any suggestions I make – and workability not just in the car while driving, but at work, while doing other tasks, at other times.

I may work together with him to find out what it is about the pain in his back that particularly bothers him. Pain itself is usually not the problem – it’s what the pain represents, the effect on doing things both here and now, and in the future. In my client’s case, perhaps his back pain is particularly frustrating for him because he values getting to work and feeling ready for anything. He doesn’t want to feel like his goals are being blocked (he doesn’t want to feel exhausted and not ready for work), he doesn’t want his back pain, and his mind is telling him he needs to be “ready for anything” even though he is in the middle of a bout of back pain. In ACT terms, he’s avoiding the negative feeling of frustration, of potential failure, of feeling exhausted and his back pain, and he’s doing what all humans do – trying to control those emotions so that he doesn’t feel them! Makes perfect sense – except that the solution (giving him a cushion for his vehicle) could pose its own problems.

I can position my intervention in a couple of different ways. Honouring the value he places on being ready for anything at work, I can talk to him about how well that’s working for him right now, given he’s having a bout of back pain. Could he be willing to allow himself to be less “ready for anything” while he recovers from his back pain? I could also suggest that he could take the time to be present to his back pain, to be aware of and experience his back – and his feet, arms, shoulders and breath – while driving to work, so that he can notice the times when it’s really bothering him, and when it bothers him less, and that along with his back pain he also has areas of comfort and strength. I could provide him with a cushion – but ask him to think about what happens when he has to sit in other chairs, and ask about the workability of carrying a cushion wherever he goes.

The point is that while occupational therapists can help people do the things they want and need to do, some of our efforts can constrain people’s options over time. We don’t live the lives of our clients – but sometimes we can assume the client’s priority is to solve an immediate problem, while overlooking the other competing values the person also holds dear.

I’ve included some readings that have informed this blog post – while they’re not directly referenced in my post, they help inform my clinical reasoning.

Damsgard, E., Dewar, A., Roe, C., & Hamran, T. (2011). Staying active despite pain: Pain beliefs and experiences with activity-related pain in patients with chronic musculoskeletal pain. Scandinavian Journal of Caring Sciences, 25(1), 108-116. doi: 10.1111/j.1471-6712.2010.00798.x

DeGood, Douglas E., & Cook, Andrew J. (2011). Psychosocial assessment: Comprehensive measures and measures specific to pain beliefs and coping. Turk, Dennis C [Ed], 67-97.

McCracken, Lance M., & Vowles, Kevin E. (2014). Acceptance and Commitment Therapy and Mindfulness for Chronic Pain: Model, Process, and Progress. American Psychologist, 69(2), 178-187.

Stenberg, Gunilla, Fjellman-Wiklund, Anncristine, & Ahlgren, Christina. (2014). ‘I am afraid to make the damage worse’ – fear of engaging in physical activity among patients with neck or back pain – a gender perspective. Scandinavian Journal of Caring Sciences, 28(1), 146-154. doi: 10.1111/scs.12043

Trompetter, Hester R., ten Klooster, Peter M., Schreurs, Karlein M., Fledderus, Martine, Westerhof, Gerben J., & Bohlmeijer, Ernst T. (2013). Measuring values and committed action with the Engaged Living Scale (ELS): Psychometric evaluation in a nonclinical sample and a chronic pain sample. Psychological Assessment, 25(4), 1235-1246.

van Huet, H, & Williams, D. (2007). Self-Beliefs About Pain and Occupational Performance: A Comparison of Two Measures Used in a Pain Management Program. OTJR: Occupation, Participation and Health Vol 27(1) Win 2007, 4-12.

Making sense of pain


Humans have an incredible desire for things to make sense. We want things to fit a story or what’s expected – and we get right discombobulated (it’s a word) if we encounter a situation where things don’t make sense. To a certain extent we can blame our use of language for this, because it’s the way we’ve learned to pair words with concepts, and to associate multiple concepts together. For example, we learn “ouch” is associated with that unpleasant sensory and emotional experience that we’ve learned goes along with scrapes or bumps or cuts. We’ve also learned that “ouch” goes along with “it will go soon” and “don’t use that bit too much or it will hurt for longer” as well as “big boys don’t cry” and “you’re just being lazy if you don’t suck it up” and “whiners talk about their back pain all the time” and other similar notions. This is how humans connect visible objects (nouns) with words and other invisible concepts to create a network of meaning that, among others who share similar language and culture, means we can communicate with one another and go beyond the here and now and into the future and recall the past.

Even when events don’t make sense, we struggle to create a sense from it – we even say things like “this doesn’t make sense” as a way to classify the event along with a bunch of other “events that don’t make sense”. 

Why does this matter?

Well, because we want life to make sense, and to understand what we and others are up to, we create meaning and sense (coherence) even where there is no sense. Sometimes we grasp at straws (otherwise known as explanations from people who may not actually know what’s going on, but can spin a good tale). And at times, grasping at these straws means we ignore our own experience just so we can  hold on to what we think ought to be there. Here’s an example: some of us have back pain. We don’t know why it started, but we try to make sense of why we experience it by drawing on things we’ve been told by others – we might blame age, lifting “incorrectly”, weak “core” muscles, or differences in how long our legs are. Now the explanation itself doesn’t need to even be accurate – what’s important is that by accepting an explanation we become less sensitive to alternative explanations, and even more importantly, we begin to ignore what our own body feels like because we think we should believe what an expert tells us.

The problem with trying to make an explanation work for us, when it’s not necessarily so, is that in adopting that explanation we may find it a lot more difficult to respond flexibly to different situations. For example, if we’ve learned that back pain happens because of poor posture (where “poor posture” means not holding the spine a certain way), then we have more difficulty doing things when we’re in situations where being hunched over is the only way to get into an awkward situation, like when we have to lift a child into the back seat of a car, or put the pots back into the back of the bottom shelf of the cupboard.

Explanations for pain

Because pain is so common, and critical for human survival, we hold deep and powerful beliefs about what pain should mean, and how we should handle it. We probably all learned that pain is temporary and generally settles down once tissues have healed. We might have learned to hide our tears and not to ask for help when we’re sore. We probably grew up knowing that if tissues are really mangled, then it really hurts, and if it’s a paper cut it shouldn’t bother us. And we learned all the myriad concepts associated with pain – like being too withdrawn or tearful means we’re not really very brave, that if we get angry and hit out at someone who’s helping us with our pain, it’s very bad. We learned that it doesn’t hurt as much when someone “kisses it better”, and we learned that we should find out what’s wrong, get it fixed, and get over it.

But what happens when pain violates our past experience and all the explanations we’ve been given before?

What if we have pain that doesn’t disappear? What if the explanations we get given don’t fit with our own experience? What if the very things we’ve been told to do to “help” our pain actually make our lives worse? What if we’re clinicians who find that all the things we’ve been told should work – just don’t.

If we’ve been good learners, most of us will be unsettled by these inconsistencies. Things don’t add up. We probably keep on looking for “the answer” that will fix the problem. We’ll probably feel guilty and perhaps even a bit embarrassed that this pain is different. We might doubt our own experience and worry that we’re being just a bit pathetic or a really don’t want to get better. Or if we’re clinicians, we may wonder if the person wants to get better, or if they’re really doing the exercises the way they should…

And this isn’t helped by well-meaning people who might suggest that we should keep on looking for “the answer” – even when doing this gets in the way of important things we want to be able to do! So we might take the pills that make us feel groggy and constipated. We keep on doing the exercises that are boring and don’t seem to change anything. We do these things not because they work – but because we think they should work. And so we all get frustrated and irritated and just don’t live lives of richness and fulfillment. Perhaps we forget what we want our lives to stand for anyway.

Difficult conversations

It isn’t easy to talk about pain that doesn’t do what it ought to. Our very human nature makes the situation difficult. I’m hoping that by beginning to think more contextually, more about what works in the here and now, about having a range of options to try so we don’t get backed into an unworkable corner just because that’s what someone has suggested should work, that we the people (those living with chronic pain and those working with those who live with chronic pain) might gently and creatively develop some flexibility around what can be such a sticky  concept. Maybe that’s what resilience is?

 

Guide, don’t instruct: how we talk within sessions


Do you remember your favourite teacher in school? Mine was Mrs Jackson, teacher of my Form 2 class (I think I was 12 years old). She was an outstanding teacher because she expected that we’d do well. She also didn’t tell us what to do – she helped us explore. And if there was one thing I’d like to have happen in therapy sessions with clients, it would be that we learn how to guide instead of instructing.

It’s only recently that I’ve learned why guiding and facilitating is so much more helpful than telling or instructing, and yes it’s because I’ve been reading Villatte, Villatte & Hayes Mastering the Clinical Conversation.

Have you ever noticed that when we give an instruction like “Sit up straight” or “Use your core” our clients attend to how well they’re doing just that – sitting up straight, or using the core – and at the very same time, they no longer attend to other aspects of their movement (or the context, or even the purpose of the movement). It’s a human tendency to focus on a particular set of features of our environment – and it certainly helps us cognitively because it means we don’t have to attend to everything all at once. BUT at the same time, it means we become relatively insensitive to other features occurring at the same time.

Rules or instructions have their place, or they wouldn’t still be being used in therapy – but their utility depends on how rigidly they’re applied. It makes sense for a super athlete to really focus on certain aspects of their performance, especially when they’re training, and especially when there’s one particular set of movements that will maximise their performance. For people living with pain, however, life is not about a set of performance goals. Instead, it’s about being able to respond adeptly to the constantly changing demands of their lives. And one thing people living with pain often have trouble with is being able to notice what’s happening in their own bodies.

Let’s unpack this. People living with chronic pain live with ongoing pain in certain parts of the body – and human tendencies being what they are, we try to avoid experiencing those sore bits, so our attention either skips over the painful area or it focuses almost exclusively on the sore bits and not on other parts (technically this could be called experiential avoidance). By working hard to avoid experiencing the sore bits, or alternatively focusing entirely on those sore bits, people living with pain often fail to notice what actually happens during movement.

As therapists, we can complicate this. We can instruct people (give them rules) about the movements they “should” be doing. We try to ‘correct’ posture. We advise people to use specific lifting techniques. We say “use your core”.

The effect of these instructions is to further lead our patients away from experiencing what is happening in their body. Instead of becoming aware of the way their bodies move, they attend to how well they’re following our instructions. Which is fine – until the person experiences a flare-up, or moves into a new environment with different demands, or perhaps we complete our sessions and discharge them into the wild blue yonder.

So, people with chronic pain can progressively become less aware of how their body actually feels as they do movements, and at the same time, try to apply rules we’ve given them that may not be all that helpful in different contexts.

We end up with the plumber trying hard to crawl under a house, carrying all her tools, while at the same time being worried that she’s not “using her core”. Or the piano teacher trying to “sit up properly” while working with a student on a duet. And the nurse, working one day in a busy ward with heavy patients, and another day in a paediatric ward, trying to “lift properly” using the same technique.

If we want to help people respond effectively to the widely differing contexts they’ll experience in everyday life, perhaps we need to take some time to help people learn to trust their own body, to experience both painful areas – and those that aren’t painful. We might need to help people work out fundamental principles of movement to enable them to have movement variability and flexibility – and to adjust and adapt when the contexts change.

To do this, we need to think about the way we help people learn new ways of moving. There are two fundamentals, I think.

  1. Guiding people to attend to, or notice, what is – including being OK about noticing painful parts of the body. The purpose behind this is to help people become aware of the various movement options they have, and the effect of those options on how they feel. We might need to guide people to consider not only pain, but also feelings of strength, stability, responsiveness, reach, movement refinement, subtlety, delicacy and power. To achieve this, we might need to spend time developing mindfulness skills so people can experience rather than attempting to change what they experience. The art of being willing to make room for whatever experience is present – learning to feel pain AND feel strength; feel pain AND relaxation; feel comfort AND power.
  2. Guiding people to use their own experience as their guide to “good movement”. In part, this is more of the same. I use words like “experiment” as in “let’s try this as an experiment, what does it feel like to you?”, or “let’s give it a go and see what you think”, or “I wonder what would happen if….” For example, if a person tries to move a box on a ledge that’s just out of reach, how many of you have told the person “stand a bit closer?” While that’s one way of helping someone work out that they might be stronger if they’re close to a load, what happens if the ground underfoot is unstable? The box still needs to be moved but the “rule” of standing close to a box doesn’t work – what do you think might happen if the person was guided to “Let’s try working out how you can move the box. What’s happening in your body when you reach for it?” then “What do you think you might change to make you feel more confident?” (or strong, or stable, or able to change position?).

When we try guiding rather than instructing, we honour the person’s own choices and contexts while we’re also allowing them to develop a superior skill: that of learning to experience their own body and to trust their own judgement. This ultimately gives them more awareness of how their body functions, and the gift of being flexible in how they approach any movement task.

Villatte, M., Viullatte, J., & Hayes, S. (2016). Mastering the clinical conversation: Language as intervention. The Guilford Press: New York. ISBN: 9781462523061

Dealing with distress


From time to time anyone who works with people trying to help them make changes in their lives will encounter someone who is overwhelmed, distressed and generally not willing to (or able to) take even a tiny step forward. It’s hard for us as therapists because, after all, we want to help people – but hey! This person in front of us just isn’t up to it!

I think many of us who weren’t trained in psychology can find it really hard to know what to do, and like all humans, we deal with feeling helpless by hoping to avoid it.

Some of us will tell people what to do – this is the way most of us were trained, so it’s what we do when under threat. We might couch this advice in fancy words, but essentially we try to get the person to make a change on the basis of our expertise and superior position. After all, the person came to us for help, right?

Some of us will feel stuck ourselves. Perhaps we’ll give up, or blame the person we’re sitting in front of. They’re not motivated/willing/ready so we stop trying and back off.

In both of these situations, the person’s actual needs at the time can be inadvertently ignored. They’re distressed and we either ignore and advise, or back off – when perhaps what they’re really wanting is someone to be present with them and offer them time to work together on the next best step they can take.

Here’s one way I’ve used to help people who are stuck, distressed and not certain.

  1. Be fully present and let them express what’s going on. This means listening, perhaps asking “can you tell me more about that?” or “it’s tough but are you willing to talk me through what’s going on for you right now?” or “what’s your theory on why you are feeling what you’re feeling?”
  2. Listen with an open and enquiring mind and heart. That means absorbing what they’re saying without trying to respond to it. At the most, you can reflect what you hear, perhaps saying things like “I think I understand that you’re feeling [sad, afraid, overwhelmed], do I have this right?”, or “From what you’re saying, you’re not sure [what’s going on with your rehab] and this is incredibly hard”, “if I’ve heard what you’re saying… is that what you mean?”
  3. Breathe and be mindful of your own response before charging on with the session. It’s OK to tear up if someone is saying something that would make you feel sad. It’s OK to feel aghast that this terrible thing is happening. It’s OK to notice your own body tighten up, your breathing change, not to know what to say. Just notice this in yourself BEFORE you respond. If you do feel something, respond naturally – normalise the experience described by the person as being something anyone in their shoes would feel, and reflect your own response to it. You can say things like “Oh that sounds like such a tough situation” or “I feel a bit tearful myself when I listen to what you’ve been through”, or “I really don’t know how to respond to what you’ve said, I’m lost for words, it’s really hard”.  The purpose behind doing this is to acknowledge that we’re human too, and get affected by what we hear. To be transparent and real so that the person is aware of your own readiness to “show up” and be fully present alongside them.  If you need a moment to catch your breath after they’ve told you something emotionally charged, say so.
  4. When you do respond, summarise what you’ve heard and ask them if that’s what they intended to mean. In motivational interviewing terms this can be called “giving a bouquet” – collecting together a summary of what the person has said, then offering it back to them to check you’ve understood (and it also shows them you’ve been listening).
  5. Before doing anything else, ask them “where does this leave you?” or “what do you think you should do right now?” or “what’s the next step for you now?” People have ideas about what to do next, most times, and we work more effectively with those ideas than if we try to bolt on some piece of advice without recognising their thoughts.

A couple of nice tools to use at this point are the choice point  , and the matrix by Dr Kevin Polk.

The hardest part of responding this way is often our own response. Because we feel uncomfortable, and we’re aware of timeframes, expectations, and because we probably don’t enjoy people crying or being angry in our sessions, we often don’t want to take the few moments needed to be present with someone who is in the middle of it all. Being present is about being there and not trying to change the situation, or rush away from it, or fix the problem – it’s about being willing to bear witness and honour the vulnerability that person has shown us. What a privilege!

It can be emotionally tough after a day of seeing people who are feeling distressed. I think this is where using mindfulness as I’ve described above can be really worthwhile. Noticing what our body is doing when someone is distressed can help us notice the work we do (and help explain why some of us don’t want to talk to anyone at the end of a hard day!). The odd thing is, that when we honour someone by being present and not trying to change their situation at the time, we often find the person is ready to move on and engage in therapy far more quickly than if we’d tried to “make” it happen. At least, that’s my experience!

A good clinician once told me “never be afraid of allowing someone to have a crisis, because after a crisis, shift happens”. I’ve found that to be true.

I’d love to know your thoughts on this post – I don’t have loads of references for it, but a couple that come to mind are:

Beach, Mary Catherine, Roter, Debra, Korthuis, P. Todd, Epstein, Ronald M., Sharp, Victoria, Ratanawongsa, Neda, . . . Saha, Somnath. (2013). A Multicenter Study of Physician Mindfulness and Health Care Quality. The Annals of Family Medicine, 11(5), 421-428. doi: 10.1370/afm.1507

Goubert, Liesbet, Craig, K., Vervoort, Tine, Morley, S., Sullivan, M., Williams, A., . . . Crombez, G. (2005). Facing others in pain: The effects of empathy. Pain, 118(3), 285-288. doi: dx.doi.org/10.1016/j.pain.2005.10.025