Expectations – and communicating

There are times when I look at the research on persistent pain and treatment, and I begin to wonder why I’m still so positive about this field! After all, it seems that although a biopsychosocial or multidimensional framework for pain has been around since the 1970’s, I’m still encountering reasonably recently-graduated clinicians who sincerely believe that whatever treatment they’ve learned is the Bee’s Knees, and Will Truly Fix All Pain. And people who firmly believe that All Pain Is X. Or Y. Or Z. And surely we should do what they say (pay the fee, get the certificate, perhaps even levels 3, 4 and 5!) and the people we see will get completely cured.

Maybe I’m just being a Grinch because it’s coming into Christmas.

Perhaps, too, we’ve all forgotten that treatments for persistent pain don’t happen in a vacuum. The people we work with have first had to recognise that their problem is something they think should be treated. Then they’ve chosen to see someone – and maybe chosen to see us, or been referred to us by someone else. These two steps in treatment response alone make an incredible difference to outcomes.

Imagine if I’m someone who thinks my lumbago is normal, something everyone gets, and don’t see it as something unusual. I might choose not to seek treatment until I’m about to embark on a long trip. I choose to see an osteopath because I think they’re more gentle than a physio (who will only give me exercises), or a chiropractor (who will hurt me!), and I don’t like needles so I avoid acupuncture. I don’t think my problem is serious enough to go see a medical practitioner and besides I think my GP will just send me to the physio.

Now imagine instead that I’m a young woman who loves to dance. I’ve had little niggles in my back before, but last night I got on the dance floor and partied like it’s 1999 (oh, that’s right, we’ve been there, done that!). Anyway I partied the night away until I slipped on some beer on the floor, landed on my butt and now my back is really bothering me. I head to my GP feeling pretty hung over and like I cannot walk because my back is SO sore.

Two reasonably common stories.

Now let’s take a look at a study looking at expectations from people seeking help for chronic pain (persistent pain). Wiering, de Boer, Krol , Wieberneit-Tolman and Delnoij (2018) examined the results of data collected from people with persistent pain. Over 2000 people took part in this study, mainly between the ages of 55 – 64. Most were women, most had been living with pain for a long time (on average 14.9 years). Most (50.7%) obtained treatment intended to reduce or stabilise (27%) their pain, and for many people the pain did stabilise (26%), or reduced to a degree (29.4% + 34% to a lesser degree). BUT, and here’s the thing: 41.8% expected a better result, while 33.3% got a better result than they thought they would.

The killer point is that although nearly 70% of people achieved or did better than they expected, and nearly 40% of patients didn’t expect very much, 30% of people were unsatisfied.

Curiously, there was little relationship between how the clinician communicated and the accuracy of the person’s expectations. It didn’t matter whether the clinicians used shared decision-making, patients felt their outcomes should be better than they were.

BUT importantly, attentive listening, having time available for the person, whether the patient trusted the clinician, and whether the patient thought the clinician had done all he or she could were important predictors of satisfaction.

What points do the authors make about communication and expectations? Well, one is that although communication is important only certain aspects of communication really rated with patients: clinicians thought “instrumental” communication was important. This is things like seeking information, asking questions of the person, asking for consent. Instead what actually helped was “affective” communication: responding to the person’s emotional subtext. Things like taking time to listen, building trust, giving people the idea that the clinician is doing all that he or she can.

There’s a caveat though, and I’ll quote directly “Low scores on the important communication aspects were related to expectations that were too high, while high scores were related to too low expectations. Apparently the perfect level of communication is somewhere in the middle. The relationship between low patient expectations and good affective communication may be a sign that it worries patients if health care providers show too much empathy and therefore come across as concerned.” (p. 6)

What can we do with this information? Well I think we can begin by recognising that helping people establish what’s important to them – what is the outcome they most value – is something often not tabled by us. We think we’re communicating clearly, but maybe not. We should also personalise treatments – help people realise that we’re not just delivering some sort of template or algorithm, but that we’re concerned about their unique needs, wants and lifestyles. We should also be warned that people seeking help from us have very high hopes that we’ll be able to achieve a lot. And of course, if we read the research, we should recognise that in general we don’t have a great track record in persistent pain. Let’s not over-promise!

I think using personalised outcome measures like the Patient Specific Functional Scale or the Canadian Occupational Performance Measure, or Goal Attainment Scaling could help us be more focused on what people want from their treatment. While pain reduction is the ideal – it’s not the only outcome! What point is there to have no pain if you’re still afraid to do things you want to do?

Wiering, B., de Boer, D., Krol, M., Wieberneit-Tolman, H., & Delnoij, D. (2018). Entertaining accurate treatment expectations while suffering from chronic pain: an exploration of treatment expectations and the relationship with patient- provider communication. BMC Health Serv Res, 18(1), 706. doi:10.1186/s12913-018-3497-8

When you need to change tack…

There are some times when things just don’t go the way you plan…Therapists don’t very often publicise when things don’t work out, but I think we can learn a lot from these situations – and the reflection process models one of the ways that we can help patients learn from every situation too. As one saying goes ‘it is not a failure, it’s a learning experience’!

So, with this particular client, I found myself in a ‘yes, but’ situation…this situation occurs when I’m asking the person to take action before they’re ready.
This man is a Very Busy Man – a ‘type A’ if you like. He’s a professional, in a senior position in a medium-sized organisation, and very, very busy. He works 10 hour days, rarely takes breaks (even lunch), and takes work home. He has had an exemplary work record, very few ‘sick’ days – but when he has abdominal pain, he can end up in Emergency Department. His admissions have increased in frequency over the past 12 months, and he is now asking for ‘something’ to help so he doesn’t have to be admitted to hospital, but can carry on at home.

As I assessed him, I thought the most important areas of concern were these:

  • when he experienced discomfort he tended to not notice it until it became overwhelming
  • when he became aware of his pain, he became very fearful and immediately used pain medication or sought medical care
  • he rarely communicated his pain concerns to anyone, and had been careful not to tell anyone at work
  • he had few friends and his relationships at work were somewhat distant
  • he and his wife were very worried about his health and were very keen to have his pain completely abolished
  • he was very capable of focusing and becoming completely immersed in his work
  • he had a limited range of relaxation or leisure activities

I started with offering him the menu of options, and mentioned that I had observed from the assessment he had completed with our service that he was finding it difficult to relax, and I wondered whether he would like to see how relaxation might help him.

His response?

‘Yes, but…’

And what came next was a long list of reasons why he couldn’t relax – his job was too busy, he enjoyed the ‘buzz’ of pushing himself to achieve, he was aiming for promotion, he was ‘carrying the load’ for other people at work….

I tried another tack, and reflected to him that he must find the thought of relaxing quite strange and perhaps that it felt unnecessary and a ‘time-waster’ – to which he said ‘yes’ and that what he thought he needed was to have his pain ‘properly managed’ and that ‘doctors must be able to find the cause of my pain and fix it’.

hmmmm… time for a moment of quiet reflection!

Once again I used reflective listening to let him know that I ‘heard’ what he was saying, and suggested that perhaps it might be a good idea to see if we could have a joint consultation with one of our doctors to review the medical situation, to ensure that he had the best advice available on whether a ‘fix’ was available. If there was a medical area for follow-up, that’s great, if not – the door was always open for him to come back.

Using the review process, I spent a bit of time thinking about what had happened – why had CBT and my suggestions fallen flat? What could I do differently?

I use a semi-standard set of questions (well, some of them are the same every time!):

  1. What did I do well? I think I went well with rolling with his resistance – using listening skills to demonstrate empathy and respect.
  2. What was not so good about that session? I misjudged his readiness to begin making changes and to see his pain as ongoing.
  3. What was particularly frustrating? For me it was that he wasn’t ready to move on from finding a ‘cure’ or ‘fix’.
  4. What was the most satisfying aspect about this session? That I recognised this and rolled with it instead of getting into a ‘yes, but’ situation.
  5. What skills did I use? Listening skills and a range of ‘motivational’ approaches including the menu and listening skills.
  6. What skills could I have used? Asking him what he wanted or thought was his ‘next best step’. Perhaps asked him what went through his mind when he experienced his pain at work, or started to feel pain and ‘knew’ he needed to go into hospital, or even asking him about what was important about maintaining his pace at work and establish the discrepancy between this value and what happened when he went into hospital.
  7. If I could wave a magic wand, what would I change about the situation? Spend more time listening to what he wanted before starting on a menu that assumed he was ready to make any changes at all.
  8. What extra resources could I draw on? Going through his medical file and working with his medical doctor to establish his readiness and what the options were – helping him come to a point of ‘creative helplessness’
  9. What would I do differently next time? Listen first, talk less, assume nothing.

Now I don’t use all these questions all the time, and some of them I don’t use often at all (particularly the magic wand one!! that would be too tempting…)
Is CBT the right approach? Yes – but with a tweak or two to make sure this person is at the right point of readiness before starting to introduce change.

I hope this post has helped you see some of my thinking style and that we never stop learning! By drawing on a range of different therapeutic styles that hold to a similar value base, we are able to respond with flexibility to people at different points in the change cycle.

If you want to continue reading about how I apply CBT and other therapies in chronic pain management – don’t forget you can subscribe using the RSS feed above (just click!), bookmark this blog, and comment!

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!