empathy

fishing

Empathy and catastrophising influence pain inhibition


When I went to occupational therapy school I was introduced to nociception and the biological underpinnings of pain. I wasn’t, at that time, taught anything about the brain, attention, emotions or any social responses to pain behaviour. Like most health professionals educated in the early 1980’s, pain was a biological and physical phenomenon. I suppose that’s why it can be so hard for some of my colleagues to unlearn the things they learned way back then, and begin to integrate what we know about psychological and social aspects of our pain experience. Because pain is a truly biopsychosocial experience. Those pesky psychosocial factors aren’t just present in people who have difficulty recovering from pain, they’re actually integral to the entire experience.

Anyway, ’nuff said.

Today I stumbled across a cool study exploring two of the psychosocial phenomena that we’ve learned are involved in pain. The first is catastrophising. And if you haven’t got your head around catastrophising it’s probably time to do so. It’s one of the strongest predictors of disability (Edwards, Dworkin, Sullivan, Turk & Wasan, 2016). Catastrophising is the tendency to “think the worst” and consists of ruminating (brooding on), magnifying (over-estimating the negative impact) and helplessness (feeling as if there’s nothing you can do).  The second is empathy, or the ability to sense other people’s emotions, coupled with the ability to imagine what someone else might be thinking or feeling. Empathy is not the same as sympathy which seems to be about the emotions a person experiences while observing another’s emotional state. In fact, separate parts of the brain are involved in the two experiences (Cuff, Brown, Taylor & Howat, 2014).

Back to the study. This study examined conditioned pain modulation in partners observing their partner undergoing a painful experience. It was carried out by Gougeon, Gaumond, Goffaux, Potvin and Marchand (2016) in an attempt to understand what happens to the pain experience of people watching their loved ones in pain. The experimental protocol was (1) baseline; (2) assessing pain VAS 50; (3) pre-CPT heat pain testing (thermode preimmersion at a fixed temperature); (4) CPT (either at 201Cor71C); and (5) post-CPT heat testing (thermode postimmersion at the same fixed temperature). What they did was ask the participants to submerge their right hand in a freezing cold waterbath while video recording them. They then asked their partners to place their right hand in lukewarm water while watching the video recording. Participants were asked to rate their pain intensity.

What they found was the higher the catastrophizing score was, stronger was their descending pain inhibition when they were watching either themselves or their spouse in pain. In women, the more empathic the women were, the better was their descending pain inhibition when they observed their spouse in pain.

This is extraordinary. Firstly, the finding that there was a correlation between catastrophising score and descending inhibition contradicts other research studies – Gougeon, Gaumond, Goffaux, Potvin and Marchand suggest that although cognitive and emotional processes underlying catastrophising increase pain perception and decrease inhibition, their experimental design may have increased pain perception during the conditioned stimulus which may have triggered more conditioned pain modulation. They also suggest that the catastrophising level of participants increases their perceived pain, explaining why it correlates with conditioned pain modulation efficiency.

Secondly, women were more distraught than men by observing pain in others. Adopting the perspective of a loved-one elicited stronger activation in regions involved in the “pain” matrix than adopting the stranger’s perspective (Cheng et al), and the authors suggest that empathy is a powerful factor involved in pain modulation while observing someone in pain. This shows that descending inhibition is influenced by physical stimulus characteristics (such as intensity or location), as well as personal cognitive dimensions. A far cry from the notion that psychosocial factors play little part in modulating our pain experience.

What does this actually mean for us?

Well, to me it suggests that we need to be aware of our own empathic response to observing someone else who is experiencing pain. Let’s put it this way: if I’m an especially empathic person (and especially if I tend to catastrophise) and I see people who are experiencing pain in my clinical practice, my own emotional and cognitive response to seeing people may influence my behaviour and practice. For example, I might be less willing to tell people that I don’t have a way to reduce their pain. I might pursue more “heroic” healthcare – send people off for more treatments, try for longer with unsuccessful treatments “just in case”, I might even send people away from my care because I find it hard to tolerate being around someone who “doesn’t respond”.

You see, being empathic and catastrophising tends to elevate feelings of distress in the presence of pain. If we don’t have effective ways to manage our own distress when we are in the presence of someone who is indicating they’re sore, we’re at greater risk of developing burnout and of feeling frustrated (Gleichgerrcht & Decety, 2014).

For this reason I’m a fan of using mindfulness because it does help people to step back from the emotional judgements of experience, and in particular the negative impact such judgements have on both interactions and emotions (Dobkin, Bernardi & Bagnis, 2016).

 

Cheng Y, Chen C, Lin CP, et al. Love hurts: an fMRI study. Neuroimage. 2010;51:923–929.

Cuff, B. M. P., Brown, S. J., Taylor, L., & Howat, D. J. (2014). Empathy: A review of the concept. Emotion Review, 8(2), 144-153. doi:10.1177/1754073914558466

Decety, J., Yang, C.-Y., & Cheng, Y. (2010). Physicians down-regulate their pain empathy response: An event-related brain potential study. Neuroimage, 50(4), 1676-1682.

Dobkin, P. L., Bernardi, N. F., & Bagnis, C. I. (2016). Enhancing clinicians’ well-being and patient-centered care through mindfulness. Journal of Continuing Education in the Health Professions, 36(1), 11-16.

Edwards, R. R., Dworkin, R. H., Sullivan, M. D., Turk, D. C., & Wasan, A. D. (2016). The role of psychosocial processes in the development and maintenance of chronic pain. The Journal of Pain, 17(9, Suppl), T70-T92.

Gleichgerrcht, E., & Decety, J. (2014). The relationship between different facets of empathy, pain perception and compassion fatigue among physicians. Frontiers in behavioral neuroscience, 8, 243.

Gougeon, V. M., Gaumond, I. P., Goffaux, P. P., Potvin, S. P., & Marchand, S. P. (2016). Triggering descending pain inhibition by observing ourselves or a loved-one in pain. Clinical Journal of Pain, 32(3), 238-245.

before the nor'wester

“Them” and “us”


The governing principles and purposes of International Association for the Study of Pain (and thus NZ Pain Society) are clear that “IASP brings together scientists, clinicians, health-care providers, and policymakers to stimulate and support the study of pain and to translate that knowledge into improved pain relief worldwide.”
There is no mention in this purpose of the people who experience pain. I think this is an omission.

Pain is a subjective experience. This means we can only be informed about pain when people communicate about it. So many aspects of pain have not been explored in a great deal of detail: things like gender, the lived experience of “good” outcomes vs “bad” outcomes, the use of labels like “failed back syndrome”, the “what it is like to be” a person receiving types of treatments, even determining whether a treatment is acceptable in the context of the real world – or not.

If we want to reduce the burden of pain within our population, shouldn’t we be incorporating the views of people living with pain? so the aims and priorities of those living with pain are included, increasing public awareness of pain and what it means to counter the prevailing attitudes towards people living with pain?

There is, however, a divide between “us” and “them”. “Us” being privileged to know about pain, to develop research agendas, to study pain and translate into improved pain relief, while “them” are passive recipients of such efforts.  This doesn’t fit with my views of the reducing gap between treatment provider and recipient, or of the relationship of collaboration that must exist between a person wanting help and those giving it. And it doesn’t afford a strong voice to people living with pain who have as valid a view as those who do not live with pain.

Is there room for a person-focused approach in pain research? And can people living with pain have a voice?

I’ve been reading some of the very old medical journals, ones like the New England Journal of Medicine from 1812. In this article, J. G. Coffin expounds on the use of cold bathing saying “For several years past from May to November, I have been in the habit of walking or riding on horseback freely til 12 or 1 o’clock of the day, hastening to the water’s edge, and plunging in with the least possible delay; and in no instance have I regretted the habit, but on the contrary have found it alike grateful and invigorating.” Now I’m not about to suggest we all begin cold bathing, but what I want to point out is the very personal nature of this account.

Compare this with an excerpt from Martel, Finan, Dolman, Subramanian et al (2015) discussing self-reports of medication side effects and pain-related activity interference: “Despite the potential benefits of each of these medications for the management of patients with pain, it is well known that the combination of a wide range of medications may lead to a number of adverse side effects, including nausea, dizziness, headaches, constipation, and weakness. These medication side effects are frequently observed in clinical settings and represent a complex pain management issue.” (p. 1092).

Patients,  not people, are discussed in the latter paper, even though the subject of this study is the experience of people taking medication for their pain. Numbers of side effects. Self-reports of pain intensity, reduced to a 0 – 10 scale. “Negative affect” reduced to numbers.  Interference in three areas of activity rated using the same scale.

While I applaud the need to measure variables of importance, I find it interesting that articles about subjective experiences of people feature far less prominently in our esteemed journals of pain research than those presenting a one-step-removed depersonalised view of what is a human experience.

In recent months I have been reading about the space that occurs between a clinician and patient. Benedetti’s writings on The Patient’s Brain (which, incidentally, also and equally discusses the clinician’s brain) help unpack that special place in which ritualised relationships including power and plea are played out every day. What I draw from Benedetti’s book is that while people seeking treatment appear the supplicants, in fact it is they who determine (to a great degree) whether a treatment will be helpful or not. The meanings ascribed to the interaction are formed by the person seeking help. Clinicians play out a role according to the “rules” of this interaction.

In a treatment setting we are but two humans meeting in a shared space. The quality of that interaction, and indeed the benefit experienced by the recipient of treatment, is strongly influenced not only by that person’s expectations, but also by the degree of empathy expressed by the treatment provider.  As Garden (2008) states “The biomedical approach to medicine all too often overrides concern about patients’ psychological and social experiences of illness” (Garden, 2008, p. 122).  She points out some of the factors that lead to difficulty with empathy in clinical encounters are often about social and cultural issues – too little time, sleep deprivation, a clinical culture that neglects clinician’s personal identity and physical experience (p. 122).

We should also know that downregulating empathy for people in clinical encounters can be a self-care strategy, as Reiss indicates in a brief paper in 2010 (Reiss, 2010). Downregulating the “pain empathy” response involves inhibiting neural circuits such as the somatosensory cortex, insula, anterior cingulate cortex, and periaqueductal gray. Downregulating these areas also “dampen[s] negative arousal in response to the pain of others”. She goes on to say “without emotion regulation skills, constant exposure to others’ pain and distress may be associated with personal distress and burnout” (p. 1605).  However, the harm caused by dehumanising, and unempathic healthcare results in focusing on organs and tests and poorer outcomes, as well as greater burnout, increased substance abuse and more patient complaints (p. 1605).

Cohen, Quintner, Buchanan, Nielson & Guy (2011) writing movingly of the potential role health professionals have in stigmatising those experiencing chronic pain. I wonder if the very way we investigate pain, the scientific model so often used to examine aspects of pain and pain management that works by compartmentalising people into “them” (usually people with pain) and “us” (usually researchers and clinicians) also leads to a sense that “we” are different somehow from people who experience pain. And hence from there to organisations established to study the pain of “them” without actually including “them”.

I wonder how many people working in the field of pain and pain management experience pain. Hopefully ALL of them sorry, US. And that means we need to begin thinking about how easily any one of us could become a person living with pain, and perhaps begin considering how we could work together to shift the societal belief that there is a “them” and “us.

Cohen, Milton, Quintner, John, Buchanan, David, Nielsen, Mandy, & Guy, Lynette. (2011). Stigmatization of patients with chronic pain: The extinction of empathy. Pain Medicine, 12(11), 1637-1643.

Garden, Rebecca. (2009). Expanding clinical empathy: an activist perspective. Journal of General Internal Medicine, 24(1), 122-125.

Martel, Marc O. , Finan, Patrick H. , Dolman, Andrew J. , Subramanian, Subu , Edwards, Robert R. , Wasan, Ajay D. , & Jamison, Robert N. . (2015). Self-reports of medication side effects and pain-related activity interference in patients with chronic pain: a longitudinal cohort study. Pain, 156(6), 1092-1100.

Riess, Helen. (2010). Empathy in medicine–a neurobiological perspective. JAMA, 304(14), 1604-1605. doi: dx.doi.org/10.1001/jama.2010.1455

hydrangea

Talking pain – seeking validation: Social interaction in pain


ResearchBlogging.org

While we might laugh about the so-called typical ‘I will fix it’ response of some men when their partners talk about problems (when what the woman really wants is a hug), it seems that much of our research into pain behaviour, particularly verbal expressions of pain, has missed something. I’m not a major reader of relationship literature, but I do read a lot about pain behaviour, and something I’ve noticed is the almost exclusive orientation toward the operant conditioning model when it comes to expressing pain in a social setting.

In operant model of pain behaviour, these behaviours are enacted to communicate to others. Responses to those behaviours may reinforce or punish those behaviours – and there is a good deal of evidence to support this model. It seems to be supported by evolutionary theory in that pain behaviours elicit resources from others, and serve to obtain help. One focus of therapy traditionally is to reduce the number of pain behaviours, in order to reduce the identification of the individual with helplessness or the sick role.

Cano and Williams, in this paper, suggest an alternative view of particularly verbal utterances about pain in relationships – they suggest considering an interpersonal process model of intimacy.

In this model, the things we say that disclose emotional content serve to foster and strengthen intimacy if they are met with empathy and validation. Cano and Williams state: ‘verbal communications about one’s thoughts and feelings about pain, may entail attempts to disclose emotion, recruit emotional support, and build intimacy.’
They go on to say ‘An empathic and concerned response from the partner may also contribute to intimacy. Emotional validation, including empathic responses, enhances the emotion regulation process for both partners because such responses allow each person to process stressful or aversive stimuli.’

In other words, if the partner doesn’t respond empathically, this is usually interpreted to mean rejection and disregard for the partner and usually negatively affects emotion regulation, but when the partner does respond with empathy, the relationship is stronger and more intimate.

What might this mean in therapy?
Well, up until now, operant theory has supported the idea of reducing or minimising pain behaviour, including talking about pain or eliciting emotional or practical support from a partner. This process model suggests that some types of communication may serve to improve the relationship. Validation of emotional content by the partner has in one study correlated negatively with punishing spouse responses, while invalidation correlated positively with punishing spouse responses – and the emotional content (rather than the words) made the major difference between the two types of response (Cano, Barterian & Heller, 2008).

This suggests that a simple ‘let’s eliminate the negative’ may not benefit the relationship. Strong relationships enhance coping, and relationships are strengthened when what one spouse is seeking is matched by the other spouse.

Empathy, caring, concern, and closeness may be desired when a person with pain discloses emotion, not ‘‘expertise” or problem-solving, which could signal invalidation of emotion.

This may mean clinicians helping partners (and families) learn to communicate more effectively – and something that has become very apparent to me is how poorly we as humans can communicate about pain, especially when it comes to setting boundaries, asking for help, or seeking emotional support. It takes a good deal of skill to express what it is that we really want, and to clarify or restate what we want if initially we fail to get it.

Assertiveness has a bad rap very often – it can mean all sorts of strident and aggressive ways to ‘get the point across’, when in fact it is simply about being respectful of each other and oneself.  A good number of factors can get in the way of effective communication such as long-standing scripts ‘I should be able to cope alone’, ‘I must not disagree’, ‘I don’t have the right to ask’, as well as limited skills in regulating emotions when the message isn’t received in the way it was hoped.

At the very least, something we can do as clinicians is listen to the people we are working with, and while we don’t want to reinforce helplessness (which, by the way, we will do if we offer ‘solutions’ rather than simply acknowledging the situation), we can help people feel more comfortable with difficult emotions if we ourselves can be mindful and allow ourselves to ‘sit with’ those very emotions.  By modelling effective communication ourselves, we can help validate and strengthen our relationship with the person, while not necessarily attempting to ‘fix’ or ‘reduce’ the distress.  Then we can turn the conversation to things that are good, achieved and helping the person move on.

Some brief pointers as to how:

  • ask about what the person has been up to rather than how their pain is
  • if they say they’ve had a hard time, acknowledge this ‘It’s been a real challenge to get here’.  Then pause – and add ‘it’s really great to see you here, how did you manage it’ as a way to move on towards positive coping
  • when they foresee snags or problems, acknowledge that it’s not easy to do what we’re asking.  Then ask what they think is the ‘next best step’ towards doing what you’re currently working on.
  • respond to the emotional content by empathic reflection, rather than getting caught up in how to solve the practical problem – that’s probably not what the person is asking for, and even if it is, empathy can go a long way towards helping the person accept that you are there for them rather than to ‘fix’ them

The paper by Cano and Williams goes on to discuss appropriate research strategies that might help us understand more about interactions in couples.  It’s difficult for me to read this without adding ‘if you can get the couple to come in!’ because so often people seem to think that they ‘should’ cope with ongoing pain alone.  It would be great to see far more emphasis on people and their relationships and social context in the next ‘new wave’ of chronic pain management.

Cano, A., & Williams, A. (2010). Social interaction in pain: Reinforcing pain behaviors or building intimacy? Pain, 149 (1), 9-11 DOI: 10.1016/j.pain.2009.10.010

Cano A, Barterian JA, Heller JB. Empathic and nonempathic interaction in
chronic pain couples. Clin J Pain 2008:678–84

It’s not what you say, it’s the way that you say it?


ResearchBlogging.org
I have a bit of a theme happening – health care interactions. I think it’s because this week I’ve been talking about this with patients, and it seems to be something that either raises the hackles or fills them with gratitude! Anyway, I was glad to find this paper the other day on ‘perceived quality of doctor–patient interaction in rehabilitation’. This is slightly different from the usual focus, which is often on interactions in primary care.

It’s an interesting paper written by a group of researchers in Germany. They describe the use of a newly-developed rating instrument, the ‘P.A.Int-Questionnaire’, which stands for (in German) ‘Patient-Arzt-Interaktion’. I’m guessing that’s German for ‘patient-doctor interaction’ (correct me if I’m wrong!). By using this, they aimed to examine the relationship between perceived quality of interaction and long-term treatment outcomes.

The quality of interactions between patients and clinicians were rated on three dimensions – affective behaviour (ie warmth, empathy, ‘coherence’); instrumental behaviour (ie information exchange, structuring and reinforcement); and participation and involvement of patients.

I’ll just briefly describe the methodology, before cutting to the findings and then going onto how this might influence practice in chronic pain management.

Two different questionnaires were developed – tapping into the same domains, but one for patients and one for clinicians.
Seven rehabilitation clinics were involved in the study, with 61 doctors and their 470 patients reviewing their interactions with each other on admission, discharge and ward round. Patients also rated their health status on admission, discharge and six months later.

The key study questions were

  1. whether there were similarities between the patient rating of the experience, as compared with the clinicians rating;
  2. what the relationship was between the perceived quality of the interactions and long-term patient outcomes;
  3. whether there were any differences between those perceiving good interactions and those who perceived interactions as poor; and
  4. whether depression, anxiety or pain intensity influenced those ratings or outcomes.

The findings?

  • Patients and clinicians both rated affective behaviour in  interactions in a similar way, and quite positively.  So people were happy with the warmth demonstrated in the consultations.
  • Instrumental behaviour (information and structuring) wasn’t viewed as positively by patients as it was by clinicians – it seems that clinicians believe they are better at information exchange and guiding an interaction than what the patients experience is.
  • Patients who were happy with the interactions they had on admission were more likely to respond well to treatment in terms of pain reduction, as well as to anxiety when they were discharged – and this was maintained even to six months after discharge.

The final conclusions from the authors of this study relate to both the questionnaire itself and the findings about quality of interactions and treatment outcomes.

Firstly they indicate that the questionnaire has adequate internal consistency and is  sensitive to different situations and subjects (with recognition that the instrument needs further work in terms of factor structure and validity/reliability).

Secondly, they identify that improvements with respect to pain intensity and pain frequency at discharge and six months after discharge were stronger and more sustainable in the patient group reporting high quality of interaction with their clinician.  Again, the authors point out thatthat there are some limitations with respect to interpreting these findings:

Patients rating their interactions as high quality also reported higher pain intensity at admission. This could mean their pain scores ‘regressed to the mean’ (ie, reduced from an artificially high level to a more ‘usual’ level simply as a measurement artifact), or that these patients obtained better interactions from clinicians because they had higher pain intensity. Another drawback to the study is the 40% of patients who were unavailable for the 6 month followup measure.
A further point the authors make is that although pain, anxiety and mood improved, functional measures did not change (good point!). I note also that information about demographics and type of patient (chronicity of problem, previous health status and so on) wasn’t available, so we can’t determine whether there were differences between clinics.

What can we make of these findings?
It seems that these clinicians were really nice people – they conveyed warmth and empathy, and their patients liked this. They didn’t, however, do so well in terms of information exchange, guiding the discussion, or ‘making it work’ (actions). This might mean that although these clinicians were nice people they maybe hadn’t developed the specific skills involved in structuring a patient interaction.

While the clinicians involved in this study were physicians, I wonder whether occupational therapists, physiotherapists, nurses or even social workers could also be relatively under-skilled in the specifics of instrumental behaviour. I’m hoping that psychologists have some skill in this area – but I’m not entirely sure.


What was interesting for several reasons was the specific finding that people who rated the interactions very positively experienced better outcomes even in the long-term.
Now I don’t want to over-interpret this finding, but it does make me wonder whether this study is tapping into one aspect of the so-called placebo effect, or ‘meaning response’. After all, one of the main differences between ‘alternative’ health care providers and those of us working in, for example, a public health system, is the time available for a consultation. At the very least, the longer time available means more opportunity to demonstrate caring and empathy, and for information exchange.

At the same time, ‘alternative’ therapists positively engage with their patients to involve them in their (sometimes) complex treatment regimes (ever tried homeopathic treatments? you often have to stop using peppermint toothpaste, eating peppermints, stop drinking tea, coffee, chocolate…and I don’t even WANT to think about colonic treatments!). Of course, we’re not given the number of patients who drop out from ‘alternative’ treatments either, so I guess I’m not comparing apples with apples here!


I think I’ll go about reviewing my interactions in terms of these three dimensions for a while – and then see what I need to learn to improve my communication with patients.

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Susanne Dibbelt,, Monika Schaidhammer, Christian Fleischer, Bernhard Greitemann (2009). Patient–doctor interaction in rehabilitation: The relationship between perceived interaction quality and long-term treatment results Patient Education and Counseling : 10.1016/j.pec.2009.07.031

Why do they want me to see a psychologist – I’m not nuts, I just have pain!


Explaining to someone that seeing a psychologist about chronic pain might be helpful can be a bit like this:

Yup, brick wall – hard object!

I can see it from the person’s point of view – it’s taken a long time (usually) for medical and other people to recognise that this pain isn’t simply going away, and isn’t about the person being ‘pathetic-why-don’t-you-just-pull-yourself-together’, so when someone suggests that psychology might be helpful it’s like saying ‘You’re nuts, you’re just losing it’ – or worse, ‘you’re a hypochondriac’.

I thought it might be helpful to review some ways to introduce the idea of seeing a psychologist (or other allied health person), or using a CBT perspective in pain management. (more…)

…it just hurts!


I was taking a quick wander through some of the headlines on my MedWorm feed this morning, when I stumbled on a headline saying ‘It just hurts’. I had to click on it and here is what I read:

Me: “Hello, so you’re having some chest pain?”

Patient: “It just hurts.”

Me: “When did it start?”

Patient: “It just hurts.”

Me: “Where on your chest?”

Patient: “It just hurts.”

Me: “Anything make it worse?”

Patient: “It just hurts.”

Me: “Ever had this before?”

Patient: “It just hurts.”

Me: “Fine, enough, I’ll just order a bunch of tests.”

Now I know this is in an emergency department setting, so things are a bit different from my chronic pain setting, but my immediate thought was that this patient was so scared he couldn’t find words to say what was happening to him – but all I read in this exchange was a doctor trying to diagnose.

It could be a life and death situation – ‘heart attack’ or something – but at the same time, I wonder what would have happened if someone had spent a moment or two reflecting to the patient that he sounded scared, that all kinds of feelings can take over when you have a pain, and that it can be hard to think straight at those sort of times. Some reassurance that things are under control now and he’s in a safe place.

I also wonder whether explaining why the doctor was asking the questions, and some of the train of thought of the doctor might have helped.  And finally, I do wonder if the patient had been told to breathe out slowly, and take some time to relax his body whether the patient might have been more ready to describe what was going on.

Sometimes in our rush to diagnose and fix, or work on ‘problems’ we can forget that developing rapport by listening and showing that we understand the emotions that happen when people experience pain is possibly the best medicine we can give.

Psychology Today has a self-test for listening skills, the brief results from which are free… fun to try out anyway!

The Motivational Interviewing website has a summary of the OARS acronym – Open ended questions, affirmations, reflections and summarising, it also gives a good description of levels of reflection:

Simple Reflection
One way to reduce resistance is simply to repeat or rephrase what the client has said. This communicates that you have heard the person, and that it is not your intention to get into an argument with the person.

Client: But I can’t quit drinking. I mean, all of my friends drink!
Counselor: Quitting drinking seems nearly impossible because you spend so much time with others who drink.
Client: Right, although maybe I should.
Amplified Reflection

This is similar to a simple reflection, only the counselor amplifies or exaggerates the point to the point where the client may disavow or disagree with it. It is important that the counselor not overdo it, because if the client feels mocked or patronized, he or she is likely to respond with anger.

Client: But I can’t quit using. I mean, all of my friends use!
Counselor: Oh, I see. So you really couldn’t quit using because then you’d be too different to fit in with your friends.
Client: Well, that would make me different from them, although they might not really care as long as I didn’t try to get them to quit.
Double-sided Reflection

With a double-sided reflection, the counselor reflects both the current, resistant statement, and a previous, contradictory statement that the client has made.

Client: But I can’t quit drinking. I mean, all of my friends drink!
Counselor: You can’t imagine how you could not drink with your friends, and at the same time you’re worried about how it’s affecting you.
Client: Yes. I guess I have mixed feelings.
Shifting Focus

Another way to reduce resistance is simply to shift topics. It is often not motivational to address resistant or counter-motivational statements, and counseling goals are better achieved by simply not responding to the resistant statement.

Client: But I can’t quit drinking. I mean, all of my friends drink!
Counselor: You’re getting way ahead of things here. I’m not talking about your quitting drinking here, and I don’t think you should get stuck on that concern right now. Let’s just stay with what we’re doing here – talking through the issues – and later on we can worry about what, if anything, you want to do about it.
Client: Well I just wanted you to know.

This example is from problem drinking, but it applies to many situations – such as when people are trying to explain why they can’t use a pain management strategy!

James T Hardee writes about Empathy in healthcare‘Unfortunately, many physicians were trained in the world of “Find it and Fix it” medicine, a world where empathetic communication was only an afterthought–if this behavior was considered at all. Empathy was known as “bedside manner,” a quality considered innate and impossible to acquire–either you were born with it or you weren’t. More recently, greater emphasis has been placed on empathy as a communication tool of substantial importance in the medical interview, and many experts now agree that empathy and empathetic communication are teachable, learnable skills’.
I think we could add in a number of other health care professionals who may have been taught listening skills early in training, but in the busy-ness of clinical life, might forget the basic skills.

Remember the reasons you decided to start working in healthcare? And the reasons you stay? There are other less demanding ways to earn a living – but we all chose healthcare. This article from Positive Psychology Daily discusses meaningful work. Perhaps one way of reminding ourselves to be empathic, compassionate and human is to remember the meaning in our work.

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Can you inflict pain without flinching?


Just for something a little different today: I nipped on over to YouTube and searched for ‘pain’ – what did I come across? Well, apart from h e a p s of really stupid ‘Jackass’ type of home video inflicting pain on each other and laughing maniacally… there were a couple of really interesting psychology clips that caught my eye.

This one made me think, particularly after considering the difficulty some therapists have in ‘pushing’ patients to do activities despite pain…(see my post from a couple of days ago ).

Jean Decety, Professor, Psychology and Psychiatry, explains his research into pain responses and how physicians learn to turn off the part of the brain that activates feelings of empathy. Decety co-authored “Expertise Modulates the Perception of Pain in Others,” published in October 2007, which discusses the necessary ability of a doctor to regulate pain perception in order to better treat patients.

It’s a quick video – so take a moment to enjoy!

Motivating people to make changes (iii)


The third of a series about using values and empathy to help people make choices

The previous two installments in this series have introduced the concepts of stages of readiness for change, rapport and empathy and appreciating that the people we work with have their own values influencing the choices they make. This paper introduces two strategies that can help people directly influence the focus of therapy while at the same time enabling you as a therapist to signal areas that are important.

From the outset of a clinical encounter, you as the therapist direct the interaction. This means you have the responsibility for ensuring the person you are working with has opportunities for choice. In order for you to find out what is important to the person, you need to ask about how their health situation is affecting them. This sets the agenda for your session.

Agenda are usually set by you – so giving the patient/client the opportunity to set what that is important to them at the outset immediately establishes your credentials as someone who will take them seriously.

We often do things that have unintended consequences in the medium to long term, while satisfying immediate desires. While we don’t always like the unintentional outcomes, it can be very difficult to resist instant gratification! While we satisfy our craving for chocolate, we risk gaining weight. Our taste for chocolate might make us feel better – but our good feelings disappear when we step onto the scales in a fortnight’s time… Similarly, the person who doesn’t want to work to quota because he ‘has to mow the whole lawns – and cut the edges’ may be reducing the immediate distress of letting the family down, but ends up being unable to go to work for a day – letting his employer down.chocolate

Part of what we are doing as we establish rapport is becoming aware of what is important (therefore valuable) to the person – and from this we can develop goals with the person that (hopefully) align with their values in the medium and long term.

Read further on this topic in my Coping Skills section.
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Motivating people to make changes (ii)


The second of a series about using values and empathy to help people make choices

The first installment in this series looked at why people might not be doing what we think they ‘should’ and how they might show this. This installment looks at developing rapport and reviews the essential interpersonal skills that are needed.

Rapport – what does it really mean? Is it just making small talk so the person calms down and is ready to listen to what we want to say? Or is it something much deeper?

Superficially, rapport is really about ensuring you and the other person are on the same wavelength. It can be as simple as asking them about the weather, or did they have a good day, or ‘what can I do for you?’ Done glibly it can be shallow and forced – and you know the person will only tell you what they think you want to hear (until they are just walking out the door and say ‘oh by the way…’!)

 

To respect this person’s situation, we need to believe that they have made the best possible choices given the resources they had at that time, and that to them their choices made sense at least once. Something about their choice was important to them at the time. Their choices reflect their values – what is important to them.

 

Although there are specific skills to help develop rapport, the first and most essential element is actually an attitude: ask yourself ‘Do I really respect this person?’ Respect means accepting that although the person is different, and has made choices that are different from yours, you can honour their position and understand that they have done so to make the best possible decision at the time.

Reflective listening is a basic skill taught (usually) early on in health professional training. It’s often assumed by both ourselves and others that we know how to use reflective listening, but sometimes our skills haven’t developed since we first learned them!

For more details – click here to go to this post in my Coping Skills section!

 

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Motivating people to make changes (i)


The first of a series about using values and empathy to help people make choices

Most of our training in health care provision assumes that:

  • the people we will be working with are ready to receive our knowledge/expertise
  • we know more than they do (about what they should do)
  • their health status is the most important thing in their lives (well, we think health is important, don’t we?)
  • all they need is for us to tell them what to do and they will go away and just do it

And if they don’t – they’re ‘resistant’, ‘not motivated’, ‘noncompliant’, ‘nonadherent’.

– and we’ve always known how they show us this!!

They may

  • say ‘yes but’ to any suggestions
  • become silent
  • become angry
  • deny they have a problem
  • interrupt
  • avoid making a commitment
  • not come back to see you
  • pretend they are doing what you suggest, but actually do nothing

By taking care to really understand the good things about the way the person is currently acting, and the not so good things about changing, we can work together to help change occur out of intrinsic motivation, or values that the person holds.

Read on…!

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