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FC2O Episode 16 - Bronnie Lennox Thompson
21 Plays5 years ago
If you think setting goals for those in persistent pain is a great place to start... think again! In this podcast, Bronnie Lennox Thompson talks us through her PhD research into how some people experiencing persistent pain continue to live well, while a higher proportion seem to be impacted more. Bronnie's work has been to understand what it is that people who live well with pain do - and how we can learn from them.
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Transcript
Understanding Occupational Existing
00:00:00
Speaker
I think this has got a lot of impact for health professionals because we usually see people in this making sense phase. In this time, people are not looking to the future. They're really, I've called it occupational existing. So it's existing. I'm, I'm trying to keep my job going. I'm trying to stay partners with my partner and look after my family and I might do a little bit of fun stuff, but actually I'm not planning
00:00:28
Speaker
goals because you know that's foreign I can't even plan next week how could I plan you know what I want to do with this pain problem yes we often start treatments thinking what are your goals what do you want out of this but if you're currently just trying to make sense and trying to predict what you can and can't do a goal sounds not not in the right ballpark yeah to abstract
00:00:58
Speaker
Yeah, and that's what these participants were saying that they felt that they were just hanging on.
Introduction to Bronnie Lennox-Thompson
00:01:34
Speaker
Today we welcome the highly accomplished, insightful and entertaining Bronnie Lennox-Thompson. Bronnie originally qualified as an occupational therapist in the 80s. She went on to train in business skills, ergonomics, mental health therapies and psychology, completing a Masters in Psychology in 1999. Specialising in working with people experiencing persistent pain, Bronnie recognised that, far from the standard narrative suggesting many people view pain as a means of staying off work, the majority of people actually wanted to get back to their work or occupation.
00:02:05
Speaker
as someone who's experienced her own journey with persistent pain. In 2007, Bronnie started her PhD on living well with chronic pain, completing it in 2014, which, as she excitedly explains on her webpage, means she can call herself Doctor, or as her kids call her, Doctor Mum.
00:02:21
Speaker
So sit back and let Bronnie guide you through her extraordinary journey, the realisation she's made along the way and how they can help us to better support those experiencing ongoing pain conditions to still live well. Enjoy the show. Here we go.
Bronnie's Career and Personal Journey
00:02:39
Speaker
Well, welcome to another edition of FC2O with me, Matt Walden and my guest today, Bronnie Lennox-Thompson. So thank you for joining me, Bronnie. It's an absolute pleasure to be part of this podcast.
00:02:52
Speaker
Excellent. Excellent. So now where are you based? I live in Christchurch, New Zealand. So bottom of the world. And we're coming into spring, which is very nice. And you're going through the most beautiful time of the year in the UK. So that's right. Yes, exactly. Exactly. And so now I know you are trained as an occupational therapist, but you've done so much
00:03:18
Speaker
in your career. I think we need to have a bit of a rundown to explain your kind of journey into where you're at now, which could take a while, but let's see what we can do. We'll try not to do too many detours. So yeah, I started as an occupational therapist and my main interest originally was in geriatric care.
00:03:40
Speaker
But it's interesting, I applied for physiotherapy for social sciences and for occupational therapy and but for a twist of fate I would have been a physio because the acceptance letter arrived for the OT first and I thought I'd never get into anything else so I quickly accepted that.
00:04:02
Speaker
Yeah, so it was a bit of a... and I also got into the social sciences as well. So I started in geriatric care and that's when I developed my own pain problem.
00:04:17
Speaker
And got the, wended my way through orthopedics and the usual kind of OT rotational positions. And while I was going through that process, I also concurrently developed, got this back pain that just didn't disappear and ended up being referred to the Auckland Regional Pain Service.
00:04:44
Speaker
where I was diagnosed by the delightful Dr. Mike Butler, who's a rheumatologist, who said those fateful words that nobody wants to hear, I'm sorry, but there's nothing we can do to help you, well, do for you from a medical perspective.
00:05:02
Speaker
And he sent me off with the book The Challenge of Pain by Mel Zach and Wall and nothing much else. And so I carried on working in geriatric care, went to another thing, another hospital, and I took three years out to be an air hostess.
00:05:27
Speaker
It's like finishing school. And I did my OE courtesy of Air New Zealand in plush, much nicer than backpacking. It was in plush accommodation, all fully funded, which was lovely. When I came back, I
00:05:46
Speaker
wanted to do vocational rehab I was really interested
Private Practice and Pain Management Programs
00:05:50
Speaker
in that area and at that time there was very little available in New Zealand especially for people who had accidents and so in New Zealand we have this really
00:06:05
Speaker
different approach to healthcare, different from the UK, different from anywhere else in the world, where we have Accident Compensation Corporation, which is a government department, and it's got paperwork galore, as every government department does, and every insurer does, and it manages all the accidental injuries, so there's no suing.
00:06:26
Speaker
Whereas anybody with a non-accident problem has to go through the health system. So at that time they didn't have any return to work rehabilitation going at all. And so I was keen to start a private practice.
00:06:44
Speaker
And as I did so, I realized that most of the people that I was seeing had pain as their major problem. And so I got interested in looking at pain and pain management. And that is how I fell down the rabbit hole and I'd never come back. So I went from there. Right, right. And roughly what year was this? Oh, that would have been
00:07:09
Speaker
I started doing private practice in 1988, something like that. And I did that through to, well, I've kept my hand in private practice ever since, but I also did some consulting work for ACC where I looked at vocational rehab.
00:07:30
Speaker
And then I was exported or imported into the South Island, because I was based in Auckland at that time, moved down to South Island and joined the Burwood Pain Management Centre, which is one of the three or four tertiary pain management centres in New Zealand. And so I was brought in there to help them
00:07:54
Speaker
establish a return to work aspect to their overall pain management approach, which at the time they were saying, you know, we don't really think these poor people with pain should really be forced to go back to work. Kind of forgetting that most of the people actually really want to go back to work.
00:08:13
Speaker
Yes, yes. So I got involved in doing some work, sort of setting up some programmes inside Burwood and concurrently continuing with consulting work to ACC to look at how do we deliver pain management.
00:08:30
Speaker
and worked on the original Yellow Flags document. I worked closely with Nick Kendall for probably 10 years and we worked together on that. I developed the work W on the Yellow Flags, W for work. That was my bit.
00:08:52
Speaker
And so then I from there did some primary prevention stuff and I did some tertiary management stuff and I worked for ACC and I've been a safe handling advisor in my wanderings and eventually landed up where I am now which is working for University of Otago as the academic leader really of our post-grad programs in pain and pain management.
Academic Role and Education in Pain Management
00:09:19
Speaker
and that's where I work most of the time now with a little tiny bit of private practice and vlogging.
00:09:29
Speaker
yes yes which is great blogging by the way yeah yeah and and so but you in amongst that you did a master's in psychology that was 1999 i believe yeah that you qualified in that yeah yeah and and a phd so you've been keeping yourself out of mischief and i was a single parent with two active children yeah madness but um yeah i really moved to christchurch
00:09:55
Speaker
in part to go to to work at Burwood but also to begin my master's so that I could go on to do PhD and I recognised that my undergrad training in occupational therapy wasn't heavy on research methods. So I majored in research methodology in my master's in psych and my
00:10:20
Speaker
thesis was, in my master's level, was looking at return to work for people, a new program that we'd develop, well I'd develop called Work Abilities, which was written, was developed for people who have done their pain management but they're not actually ready for return to work, they needed something.
00:10:38
Speaker
more. So we developed two programs. One was looking at returning to work for people who already had a job. And so that program evolved into a thing called Work Plus Skills, where people were working at work and they'd come and attend two days a week in our outpatient program. And they'd graduated already from the basic three week pain management program.
00:11:03
Speaker
And then we also developed one called Pathfinders for people who didn't have work to return to and who needed to change their jobs and needed to look at, well, how do I represent myself as a person with pain in a workplace where everybody knows you don't employ somebody who's got a bad back?
00:11:24
Speaker
Yes, yes right. So and that was that was my master's and then I went on to PhD it was kind of a logical progression for me too.
Living Well with Pain: Resilience and Persistence
00:11:34
Speaker
I was really interested in looking at people like my partner who has ankylosing spondylitis
00:11:44
Speaker
but who has worked for his whole career. So he works in the mortuary, so he's a mortuary technician, and at the same time works as a high country firefighter. He's retired from that now, but at the time that I've sort of first met him and got interested, his angst bond was really
00:12:07
Speaker
revving up badly and so he was having, we had trouble rolling at night so I put a sliding sheet under him so that we could roll because he couldn't cough. His angst bond was really aggressive and eventually went on to Humira and he now has no pain which frustrates brother.
00:12:32
Speaker
because he's still very active and so my thought was well I hear every day these stories of people who are not managing and yes I've got this man that I love with who has intense pain and
00:12:48
Speaker
but is actually working full time and we see in the media very often reports of this person has osteoarthritis but they are still doing blah blah blah and we have Mahi Drysdale gold medal winning winner who has
00:13:05
Speaker
in rowing and he has angspond. We have a guy, Matt Lockwood, who is a V6 racing car driver. He has arthritis, rheumatoid. There were just so many mentions of these quite prominent athletes who had significant pain problems, but who carried on. And it intrigued me that we know next to nothing about them.
00:13:35
Speaker
So I wanted to find out. Yeah, and I think that's that's one of the fantastic and innovative aspects of what you've done is, you know, one of one of the guys that I've done a lot of learning with is Paul Czech and one of his kind of
00:13:53
Speaker
views on health and disease is that medicine often studies disease, which of course has its place, but that actually if we can study the healthy and understand what they're doing, then that might give us more clues as to what optimal strategies are for living well. And this is really the whole sort of theme behind what your research has uncovered, is that
Classical Grounded Theory in Pain Management
00:14:19
Speaker
right?
00:14:19
Speaker
That's exactly the picture. What we know about, if we look at our research about pain, we'll find out all the things that are hallmarks are somebody who isn't going to cope. And all of our treatments predicated on the idea that this person has a deficit or an inability or something wrong with them. And we need to correct that so that they can go back to being normal.
00:14:47
Speaker
without recognising that somebody who lives well might not be doing the inverse of somebody who's doing poorly. Because pains and disability is a biopsychosocial phenomenon, we can't assume that individuals alone are going to be different just because they're living well. It could be their social circumstances.
00:15:15
Speaker
it might be that their disease process is different, it might be that they have different kinds of work, it might be that they use coping strategies and we don't really know. And to date there are only about three, there's two models and
00:15:33
Speaker
one strong research group really looking at resilience or task persistence. And Zautra and colleagues, the prominent researchers looking at this at a different kind of model that looks at this individual and the characteristics that person has. But I'm an OT.
00:15:56
Speaker
We look at people in context. So I was intrigued at not the individual differences but the trajectory over time.
00:16:06
Speaker
because we see people usually with pain when they're at their worst. We don't see them when they're really good. They come to us when they're distressed and they're given up or they're fed up or whatever. And so we don't see them in the positive, flourishing, coping end. And usually if we do an intervention with somebody, they go away and we hopefully never hear from them again.
00:16:36
Speaker
except when we do and when we do is when things are not working out. So our picture of somebody with chronic pain is somebody who is catastrophizing, is disabled, is distressed, is not coping. And yet over time, people's presentations fluctuate and vary. And they vary depending on what, you know, where are they at?
00:17:02
Speaker
And pretty much everybody who gets an unexpected pain problem that hangs around for two or three months is going to start wondering, what is this? What have I got wrong with me? And that's when they start to seek help, when it's hanging around too long or it's getting in the way of doing what the person really wants to do. And what we don't see is what happens over time as perhaps they get older,
00:17:28
Speaker
Perhaps they adjust to the disability. You know, is it that people change their ideas about what they can do? Do they change their goals so that the end points are a little bit softened? Or is it because people around them are kind of changing how they respond? We really don't know. And we've got a little bit of stuff around longer term trajectories with low back pain, but we don't actually know
00:17:58
Speaker
much about how those trajectories occur. We're looking at individual predictors rather than contextual systems-based relationships that occur.
00:18:15
Speaker
Yeah, so this links in with the fact that you use this classical grounded theory to help identify what's called the main concerns for these people experiencing persistent pain.
Making Sense of Pain
00:18:31
Speaker
And I think, obviously, when I first read that, I didn't know what you were talking about. And now I have a bit of an idea because I've read around some of your work. But could you explain why that's quite an important start point and why you chose to use this classical grounded theory to help identify these main concerns? So grounded theories, it's a really common, quite a popular methodology for studying
00:19:00
Speaker
phenomenon that there is little or no existing theory. To start with a theory you're assuming a lot. If you want to grab a theory you're assuming that the people that you're looking at look similar
00:19:17
Speaker
and involved in the same phenomenon as the theory posits. But there isn't anything. And there certainly wasn't at the time I started my PhD. Zoucher's work was very emergent at that time. So I chose grounded theory because it is really good at using real world data and from that being able to generate
00:19:41
Speaker
conceptual models or relationships between factors that you identify. I chose classical grounded theory for a peculiar reason. So there are three different versions of grounded theory. There's constructivist which says really we construct a relationship and a meaning between me as a researcher and you as a participant
00:20:05
Speaker
And together we create this thing that's very contextualized in today and that stuff. And what that means is that we can't take the concepts that are developed out of that and do hypothesis testing because that violates the assumptions of a constructivist stance.
00:20:28
Speaker
which is that it's a person's construction of what happened. With classical ground theory what we're doing is very much more like
00:20:43
Speaker
positivist or post positive view where we can stand back and we can observe events as if we're not involved or we're only peripherally involved so like we can observe that a tree falls over and we didn't have to actually touch the tree it just fell so we get this idea that you know trees fall over
00:21:09
Speaker
In classical grounded theory you're standing back and you're looking at a phenomenon that you will detect from any kind of data. I happen to use interview and questionnaire data but you could use records, you could use existing records of something, you could use, you can use any kind of data according to Glaser. So I really wanted to get something that meant that at the end of it I can test
00:21:38
Speaker
these constructs and the relationships that I've found to validate or to do the empirical side. Because in classical grounded theory you're doing just hypothesis generation rather than confirmation.
00:21:58
Speaker
Other forms of grounded theory don't, Strauss and Corbin's version, they do that confirmation as part of generating the theory. But Glaser said no, our job's to just generate some new theory and somebody else should pick it up and test it. So that's why I chose it.
00:22:19
Speaker
Yeah, and part of the reason I wanted you just to explain that is partly obviously, if people want to read into your research, that gives them, you know, more background. But also, the name of the podcast is From Chaos to Order. And the idea here being that that order emerges from chaos, you know, in chaos theory or existence theory. And I feel that a lot of the way that our work is going, particularly, you could say in pain neuroscience, but I think in healthcare in general, is
00:22:49
Speaker
the importance of using a systems approach and the ability to see these interactions between different systems and patterns emerging. And that's essentially seems to be what you've done in a formalized way with your PhD.
00:23:05
Speaker
That's exactly what you do. So we have people describing an incident that happened to them. And then I go to the next person and I find that they're saying the same thing. They've had a similar experience, but they're describing it. So we're really collecting similar patterns of behavior or interactions or experiences.
00:23:28
Speaker
and grouping them together. And the process is very formalised for classical grounded theory. It's incredibly labour intensive and you live, eat, breathe the data that your informants are giving you.
00:23:46
Speaker
But out of it, you have these consistent empirical phenomenon. For example, every person in my study spent some time trying to make sense of what was going on.
00:24:03
Speaker
And I use the word making sense and everybody knows what that means to them. The way that my participants described it is they really wanted to know what's the name of this thing. So we called it naming. So there's a process that people go through to get the name of what they've got.
00:24:22
Speaker
and it's the detail varies but the purpose or the function of doing that is to get a name that's like a shorthand abbreviation oh I've got ankylosing spondylite I've got fibromyalgia and that's meaningful because to the participants it said this is no longer mysterious this is not spooky
00:24:47
Speaker
I pretty much know the outcome of what's gonna happen. I'm gonna probably have to learn to live with this because there is no cure.
00:24:57
Speaker
which is not what people want to hear, but it was from my participants was an important part. They heard that there's a name for it. And by the way, it's not going to be fixed. We haven't got a cure. So in terms of the main concern, Glazer is saying that people are actively trying to resolve this situation.
00:25:21
Speaker
puzzle that they're involved in. And the main concern expresses that. So most of these guys or all of these guys said, you know, I used to be this person. I'm not anymore. So who the hell am I? And how can I still be me, even though I've got this experience, this pain thing that's happened that's taken so much from me?
00:25:44
Speaker
And that's really what people who are trying to manage the pain are trying to resolve.
Predicting Pain's Impact on Activities
00:25:52
Speaker
How can I still be myself? You know, I was this person who was competent, hard worker, a real bloke playing with my kids. And now I'm this weakling, pathetic person who can't do anything.
00:26:04
Speaker
And what I discovered was that for them, their process was to, how can I get back inside myself? How can I re-occupy the self that feels familiar again? How can I recreate it? So I discovered that there are really
00:26:23
Speaker
three parts to the process you know making sense is the first bit deciding at some point that well if this is the way it's going to be then I'd better just get on with life and then this final ongoing lifelong process of flexibly persisting of you know still maintaining what I really need
00:26:43
Speaker
And it's been remarkable when I've talked to people who live with pain to have them validate that that's the process, that they all describe at some point deciding, and it's almost an immediate 180 turn from, oh my goodness, I need to know what this is. I can't make sense of this too. Well, if this is the way it is, then I just have to get on with my life.
00:27:11
Speaker
and that was quite magical really, it was quite special. Yeah, yeah, yeah and I guess some people might be thinking now you know obviously we know that making a diagnosis or putting a name on something can be a double-edged sword in some instances or certainly could be perceived that way now
00:27:32
Speaker
what you've just expressed seems to be that in general it's going to be a positive thing to name it, but is there a kind of potential nocebic effect there? I guess it depends what you name it. Well yeah and it's the naming
00:27:49
Speaker
was also interesting that when people were saying, and this is mentioned in my thesis but not so much in the paper because we have to cut words out, was that when the naming happened that named thing needed to match that person's illness representation. So yeah if you think about Leventhal's common sense model, so that model says that people have illness beliefs about this is what
00:28:18
Speaker
what it's like when you have a cold. This is what we expect. And when they have those beliefs, if what they're experiencing or the label that's given to that doesn't, they don't match up, then they don't resonate with that label.
00:28:36
Speaker
And so they'll continue to look until they get a label that does fit with the experience of those symptoms. And that's exactly what the participants said to me, that they would, and until either somebody explained low back pain equals this, and your low back pain is this, they were somewhat hesitant about it.
00:29:03
Speaker
And that particularly happened with low back pain, which I didn't include in my study, in my PhD, but I've subsequently looked at. It did happen with fibromyalgia.
00:29:18
Speaker
But low back pain is a particularly complex one because the illness representation in our general community is that back pain gets better. If you have back pain it should go and if it doesn't go then something is seriously wrong when we need surgery or we need an MRI.
00:29:36
Speaker
And so that's a particularly sticky belief. And it means that if somebody says, well, you've got back pain and you don't need X, Y, or Z, it's harder for that person to reconcile it. So people need to have a conversation around what does this label that I'm giving you actually mean so that it matches the person's illness experience. So it's kind of unpacking.
00:30:05
Speaker
Thereafter, it's pretty easy for people to say, oh well I've got, and they'll give the name, psoriatic arthritis, and this is what it is. And it's kind of a shared representation between them.
00:30:21
Speaker
Yes, right, right, okay, and so then that helps to explain that first making sense component, and then the second component...
Energy Allocation and Resource Management
00:30:31
Speaker
So there's two other bits, so naming is one part of making sense. There's predicting, which is the bit that at the moment I see is not being facilitated.
00:30:45
Speaker
right by anybody and perhaps this is something that occupational therapists in particular could look at but also physiotherapists in that this is about what can I what is the impact what is going to happen with my pain if I do x what's going to happen
00:31:03
Speaker
How long can I do it for? If my pain is doing this, can I predict what I do? So if you've got a very predictable pain problem and osteoarthritis is a pretty good one for that, you know if you do X you'll get this amount of pain and it'll probably behave like that and then calm down. If on the other hand you have a neuropathic pain where it's often quite unpredictable,
00:31:32
Speaker
People are not very good at predicting whether it's going to bother them today or not. Or we've got somebody who's really just looking at the physical aspect, so movements that they believe influence their pain. And they're not aware of stressors, whether they're good, you know, it's Christmas and I'm happy or not so good. I'm really stressed at work.
00:32:01
Speaker
they're not as capable or as aware of the influences of those things on their pain and what they do. So this is kind of a reciprocal interplay between my experience of pain and my activities with an idea of what
00:32:22
Speaker
the factors that ameliorate or exacerbate pain and their impact on doing. So it's really strongly influenced by beliefs, but it's also experiential when people do this by doing. And we pretty much don't help people discover this unless we've got somebody who's seriously disabled and we ask them to keep a pain diary. And they're horrible things.
00:32:50
Speaker
I hate the fix but this is an internal process that people do by themselves and often without commenting and they maintain. Even when people are inflexibly persisting they're still noticing what is happening to their pain so they're constantly tracking it and we don't talk about this.
00:33:14
Speaker
because way back when I started working in this area 30 years ago, well not quite, it was thought that you shouldn't track pain because that's going to focus attention on pain and it does. Whereas the participants in my study were saying well I need to know because you know that helps me calculate where I put my energy
00:33:41
Speaker
Right. Yeah. Because when we go on to the next part, they're saying, well, where should I spend my energy? I shouldn't spend it on stuff that I'm not, I don't value. I should spend it on things that I do value. And if you can't track or you don't know your
00:33:58
Speaker
how to predict what you can and can't do as a result and how much energy it's going to use, then you can't really allocate your resources effectively. So that's the second process.
Clinician's Role in Pain Management
00:34:09
Speaker
And then the third process at that time, and I think this has got a lot of impact for health professionals because we usually see people in this making sense phase.
00:34:20
Speaker
in this time people are not looking to the future they're really I've called it occupational existing so it's existing I'm I'm trying to keep my job going I'm trying to stay partners with my partner and look after my family and I might do a little bit of fun stuff but actually I'm not planning goals because I
00:34:41
Speaker
you know, that's foreign. I can't even plan next week. How could I plan, you know, what I want to do with this pain problem? So we often start treatments thinking, what are your goals? What do you want out of this? But if you're currently just trying to make sense and trying to predict what you can and can't do, a goal sounds not in the right ballpark. Yeah, to abstract.
00:35:09
Speaker
Yeah, and that's what these participants were saying, that they felt that they were just hanging on, getting their sleep together, trying to remember to take medications, perhaps that they'd never had to take before. They were often trying to know how much of a job they could do or not. They were just hanging on to their job, their employment.
00:35:32
Speaker
Those sorts of things were very day-to-day things when they were saying, the physio says, what do you want to be able to do? And I just want to be able to do my gardening and keep my garden from being overrun. And it wasn't something new and marvelous and exciting. It was, I just want to do the basics.
00:35:52
Speaker
So that's the first, the big process. And I think we see most people at this phase. And what we hope to see is a bridge that we act as a bridge to moving on to flexibly persisting. This is where perhaps we don't always tap into what might help somebody flip over into that. And that's two things. One is to be trustworthy.
00:36:22
Speaker
As a clinician, are we cheerleaders? Do we wave the flag and say, hey, I'm on your side? And yes, you want to do something really wacky and I don't agree with it, but hey, it's your body. It's your life. Have a go and I'll be there for you.
00:36:37
Speaker
I call them little acts because they all described somebody who did that little something extra like showing them particular exercises that were for them. I looked these up on the internet just for you. Do these ones, don't bother with these ones. Or they'd call the person up and say, hey, how did you go after our session last week?
00:37:02
Speaker
how are these meds going and they did little things that meant that this person was felt like they were seen as an individual and were supported irrespective of their decisions and I thought that was fascinating and this sort of era of person-centered care
00:37:22
Speaker
And there's a bit of a challenge in trying to deliver personalized care within an idea of we've got to be efficient and he's an algorithm and by the way a computer program could do just as well as me. What patients are wanting was this connection with a human.
00:37:44
Speaker
And I thought that's amazing. So they had to have somebody who was there, who was that person. And then the second part was they all had this occupational drive. So something that they did that made them feel like who they were.
00:38:01
Speaker
So it could have been, one of the guys was, I've used him a lot as a rugby player. He had been a rugby player in his youth and at 19 was told, well you've got osteoarthritis so you better stop.
00:38:17
Speaker
And he did.
Occupational Drive and Identity
00:38:18
Speaker
I met him at 67 and he said he'd tried not doing rugby, but he just felt that just wasn't him. And so he started just, you know, being around the rugby guys. And then he started to do some coaching and some refereeing. And then he started to get involved in Masters Rugby. And by the time I saw him,
00:38:41
Speaker
He was playing master's rugby and had been for some time and working very long hours. This was in the beginning of our rebuild post-earthquake in Christchurch. So he was cycling to work 10Ks and then driving a concrete truck for a 10-hour shift and then cycling all the way back at 67.
00:39:06
Speaker
So, you know, it's pretty cool. So when they have this person who's on their side, a clinical person, to say, I'll support you no matter what you want to do, and they have this occupation, and I'm using that as an OT would use, so a meaningful activity that is personalised to you as a person,
00:39:31
Speaker
then and they'd also made sense so they had a name for it somebody had told them and it's not going to go away and they'd be unable to begin to predict what was happening and they were just holding things together at some point they said okay I'm gonna get on with life
00:39:49
Speaker
They couldn't tell me the timing of that, but they had all described doing the making sense part first. That was the important thing. We see people at that making sense stage and we occasionally get somebody who's in the I'm deciding
00:40:13
Speaker
But most of the people that we would see, especially with persistent pain, I would venture, are still confused because they haven't got a name for it. They can't predict what's going on and they're just hanging on. And they haven't felt that they've got this trustworthy clinician who's on their side. And maybe they can't see that they can do this thing that makes them feel like themselves.
00:40:43
Speaker
So that's where we can help as as clinicians that we can help people recognize that they can still do elements of the occupation that matters to them because I've framed this.
00:40:59
Speaker
Well, I didn't know that I was going to frame it this way. And I didn't know that it was going to be occupational drive that mattered to these guys. But it does fit nicely into acceptance and commitment therapy. Yes. We have values in committed action matter. And so what people are described doing was when they found that occupational drive, they looked at ways that they could live those values, still do those values. If I've got to be a good dad, what else can dads do apart from play rough and tumble with the kids?
00:41:29
Speaker
Yes. You know, if I want to be a provider, how can I be a reliable worker when I can't do what I used to do as a foreman on a building site? How else can I do that? And once they've been able to do that, that is like a flip to switch. They switched on to, OK, I'm now doing everything I can to learn coping.
00:41:57
Speaker
and to engage in this occupation that matters to me and now I can begin to make these future plans. So this is the flexibly persistent but that's a lifelong kind of thing.
Coping Strategies: Mindfulness and Movement
00:42:13
Speaker
So they want to
00:42:15
Speaker
they start to engage in that occupation. They find ways. And so these guys did this without somebody giving them a hand. They just did it. They naturally found ways to still be a good mum, still, you know, the guy that wanted to be a racing car driver, that helped him decide from, I'm not going to be a couch potato anymore. I'm now going to go to the gym because I really want to be this racing car driver, which is awesome.
00:42:45
Speaker
That's amazing. In your paper, don't you say there's somewhere between 13 and 36% of those living with chronic pain will tend to develop this kind of living well approach. Yeah. And that's an interesting figure because again, we don't study them because these people are not generally seeking treatment at this point.
00:43:10
Speaker
They're the people who, you know, they've got their angst bond, they've got their meds, they're just getting on with life. And so they will go off and do what it is that they want to do. And so when we see, when we do a epidemiological study, we're generally asking for people who have got problems,
00:43:33
Speaker
Or when we look at our cohorts that come into pain management, we're looking at people who've already managed to jump through all the hoops to get referred. Whereas these guys haven't, because I selected people who hadn't been part of any pain management program. So they were naive to self-management.
00:43:55
Speaker
Which is also really interesting, because then they said, oh, I'm going to have to learn some coping strategies. If I want to be a rugby player or, you know, play in Masters Rugby, what do I need to be able to do? And that made the coping strategies meaningful.
00:44:12
Speaker
Yes. So one of my concerns is that we might try teaching people things like activity pacing, but at least it's really helping them achieve something meaningful for them. They'll probably look at it as a nice piece of theory and it doesn't apply to me.
00:44:31
Speaker
Yeah, it's horrible. So I found in their coping that they all used what I've described as non-judgmental awareness or mindfulness. So they track the pain, they notice their pain, but they don't freak out. Yeah.
00:44:49
Speaker
they just notice, oh yeah, I've got a high pain day to day. That means I'll probably not spend as much energy on this. I'll prioritize that. Yeah. And is this part of why mindfulness, do you think this is part of why mindfulness has been shown to be quite an effective intervention for many people experiencing persistent pain? It's interesting because none of these participants had learned mindfulness.
00:45:17
Speaker
Yes, yeah, it was kind of habit. It was just that they said that, yes, I've got this pain, but it's only noise. It's not, it's not, it doesn't mean anything significant. I'm not going to worry about it.
00:45:30
Speaker
And do you think they kind of intuited this idea that because we obviously we as as clinicians we often talk about hurt doesn't equal harm and do you think they'd almost intuited that themselves or come to that conclusion? Yeah they realized that yeah it's just a noisy it's a bad pain day today and it's okay and it was like that sense of
00:45:52
Speaker
it's it is just noise but i need to know it because it'll tell me how much energy i've got it was like because the burden of pain is not so much and it's painful and i can't think straight it was that it's taking energy out of me i would otherwise allocate to other stuff so a high pain day means that i'm i'm just a bit less i haven't got as much resource
00:46:18
Speaker
which I thought was quite interesting. They didn't use mindfulness. You're gonna love this because you're physio. They loved doing movement. And they incorporated that movement as a way of getting head space.
00:46:41
Speaker
So they went to, they walked, they cycled, some of them went to the gym, most of them walked or swam. Something rude. I do love that for a number of reasons. But one of the reasons that links in with everything you've been talking about is, I know we're probably going to move into this idea a bit more of self-coherence and this idea that they're kind of rediscovering their
00:47:10
Speaker
their sense of self. But one of the things that I've been aware of over the last decade or so is this idea that walking in particular is excellent for integrating the two hemispheres of the brain. So it gets both hemispheres online and creates this kind of
00:47:29
Speaker
crossed extensive pattern, which we've known about this, obviously, in exercise rehabilitation for many, many years. But it does and it links in with a quote from a guy called William Stafford, who says that sometimes the truth depends upon a walk around the lake. Yeah.
00:47:49
Speaker
And I think what he has intuited there is this idea that just by going for a walk, particularly out in an open natural space, but going for a walk integrates those two hemispheres. It moves you into this bigger picture view of things and allows you to make sense of the situation that's before you. It's almost like dreaming.
00:48:12
Speaker
but you're awake. It's letting those things filter through. And it was fascinating because at the time, John Kirwan, JK, a great JK, so he was a rugby player for those of you that don't know, how could you not know? He talks about mood. And so he's been this real spokesman for men with depression. And what he says is exercise. It just makes me feel better.
00:48:42
Speaker
And I see this happening with these people. It would not have, it wasn't necessarily walking or cycling or whatever. It could have been gardening, but whatever it was, it was whole body movements. It wasn't done to strengthen, to straighten, to correct. It was done maybe as getting to and from work.
00:49:04
Speaker
but it was primarily there so they could clear the head and just let things free up. And I think mindfulness is used as a means to an end. You will become relaxed. Well, these guys are saying, no, I just noticed, which is precisely what mindfulness is meant to be. And they use their walking or their movement as their form of mind
00:49:33
Speaker
meditation if you like. And then there was the other group of things they did was anything that helps which was quite idiosyncratic.
Flexible Coping Approaches
00:49:47
Speaker
So my lovely man with his
00:49:50
Speaker
who's a rugby player and concrete truck driver, he had a set of coloured lights that he sat under for 30 minutes a day that he swore was the thing that helped him.
00:50:06
Speaker
And the participants were, you know, they were not, I was expecting to have a list of proper good coping strategies and improper strategies that they didn't use. Well, that one blew out of the water because they did things like booming and busting.
00:50:24
Speaker
And they did things like resting. One woman described resting. She said, so what if I organize my day so that when I'm feeling better, I can do more and when I'm not feeling so good, I can rest. I'm getting what I want done done and sustainable.
00:50:41
Speaker
and it kind of rocked my world because pacing is this this almost god-like rule that thou shalt do no more on a bad no more on a good day and no less on a bad day but these guys were saying hold on if I've got this really important thing that I want to do I need to allocate time and energy to that and I can delegate other stuff and I thought to myself as I listened to them describing this that
00:51:10
Speaker
actually that's what we do and I have pain but you know pop me as someone who doesn't at the moment but if you think about Christmas Day we rush around like blow arsed flies to get the family stuff done so that hopefully on you know Christmas afternoon we can just chill.
00:51:29
Speaker
And maybe Boxing Day if you don't have a teenage daughter, you can just blob. If you do, you'll be out doing the Boxing Day sales. But you know what I mean? But you know, we do this. If we have a four year old's birthday party, we will move heaven and earth to make sure that it goes off beautifully.
00:51:49
Speaker
and then we'll crash and that's what these guys were describing and so when they talked about their coping strategies they said I'll evaluate I'm not going to turn anything down but I'll evaluate whether it fits in with my life and how I want to be and my priorities
00:52:09
Speaker
not whether it's going to help reduce my pain or other people think it's a jolly good thing. I thought that was fascinating because we've got these almost rules about what we meant to demonstrate our effective, active coping strategies.
00:52:28
Speaker
Actually, it's not quite as simple as that.
Context in Coping Strategies
00:52:32
Speaker
And so if we look at contextual behavioral science and we start looking at workability and context, what seems to me is that in the right context, resting is one strategy.
00:52:48
Speaker
that we can use from time to time, as is booming or pushing through, as is chunking things up, as is any of our strategies. Where we get caught up is where people start to apply one strategy everywhere.
00:53:09
Speaker
And I think we have not always recognized that. So when we look at our coping inventories, they divide them into active and passive, which is almost viewed by us as good or bad.
00:53:26
Speaker
And I don't know, having listened to these people, I don't know that that's the truth. And I think we could probably be a lot more flexible, which is harder for us, because we like rules, because it's easier. And what we're asking people to do is to decide in this moment, what is my next best step? Should it take me towards who I want to be, or is it going to take me away?
00:53:54
Speaker
and that's very act thing, probably notice, but it means that people are judging their next best step on the fly and as clinicians we
00:54:08
Speaker
Our job might be to help people to do that mindfulness step of stop and consider, make this a choice point for what do you think the next step might be? If you do this pushing, are you doing it knowingly and are you making time for the recovery? Yeah, yeah.
00:54:30
Speaker
so that you're allowing a lot more flexibility and people can respond to the demands that constantly change in their daily lives, rather than, oh no, I can't do that because I'm pacing.
00:54:45
Speaker
You know? Yeah, yeah. So really that they're having to, or the advice or encouragement is for them to work on listening to themselves better in the context of their kind of evolving new sense of self. Yeah. And kind of thinking too about, because they're involved in occupations that are valued, so it aligns with the values,
00:55:13
Speaker
for them to think about a bigger picture of which again falls into act I'm afraid
00:55:25
Speaker
Yeah, OK, but but it's just me people are not looking at the short term. Most of our pain management is asks people to think beyond the immediate and yet most patients are living from moment by moment. And if you think if they're in that process of making sense, that's exactly what they're doing. They're trying to make sense of what's going on. They're just hanging on when they're flipping into this other
00:55:55
Speaker
perspective what we can offer people is are you aware that the short-term benefits of this strategy are this and oh here's the longer term effects because people don't know that they don't recognize those patterns in themselves necessarily and it's something that we can help people do say are you aware that you are really pushing yourself really really hard and what comes up for you when you try not to push
00:56:24
Speaker
And this is where our work then begins to say, how do you deal with the thoughts and the feelings that come up when you start to change how you do things? Because that will often conflict with other important values.
00:56:45
Speaker
So if we have a chap who's a really hard worker and who values getting a job done, do it right, do it once, do it right, do it the first time and doesn't believe that it's okay to ease up at all, but sees that the other value is I want to have enough energy to work
00:57:04
Speaker
to be a good partner, good husband to my wife. What we can do is work with that value that yes, I want to be a really hard worker and I also want to be a really good husband. How can I resolve this conflict so that I don't push myself so hard that I've got nothing left over for my wife? So those become much more meaningful,
00:57:33
Speaker
aspects of therapy, because it's really easy to teach somebody how to, you know, pace really. The hard part is putting it into practice and to put it in lots of different contexts where we have multiple values at play. Because if, when you hang on to the value, the, the, why is this so important to me?
00:57:57
Speaker
which is how we feed our self-concept. You know, self-concept's made up of what we do, why we do it, and how other people respond to us. And when people are re-engaging, re-occupying themselves, what they want to do is highlight the things that make them feel the most like themselves while letting go or loosening the relationships, the relationship with values that are less like them.
00:58:27
Speaker
And a little work on self-concept is quite complex, and it looks like we have this idea of who we are through what we do and how others respond. And if these compete, people feel uncomfortable. I want to be a good leader, but I also want to be a good husband, which one's most important at the moment.
00:58:49
Speaker
And it's then that they have to say now which part of me is the one that's most crucial, that means the most to me. And it seemed to be that's the resolution part that people were actively working through.
Gender Roles in Pain Management
00:59:07
Speaker
And I don't have an easy answer to how do we help people do this because the people that I talk to really didn't have a language to describe that part of what they were doing. Yeah, yeah. And I guess there's a real biopsychosocial element to this from the perspective that
00:59:27
Speaker
When we're talking about people's occupation and their meaningful vocation, if that's the right phraseology,
00:59:39
Speaker
know of course we can have individual ideas around what that is but then there's also social ideas around what that is and you know one of the things that struck me when I was reading your paper is of course we do know that there's a high incidence of persistent pain in women and socially I was wondering how much the occupation side of things and this kind of
01:00:03
Speaker
challenge that we see in the workplace of women, obviously biologically, so taking the bio of biopsychosocial, being the mothers and having these maternal drives and often having this conflict between the maternal drives but also the occupational drives and then but being a mother is an occupation but then they've also started out on another career path and
01:00:26
Speaker
I wonder how much of that may be playing into this higher incidence of persistent pain that we see in females. We do know from rehabilitation study that women find it more difficult to engage in rehabilitation because they very rarely
01:00:45
Speaker
are able to relinquish their mothering jobs, you know, the household management, the cooking, the meals, the caring for children. And so they compromise their own rehabilitation because they're trying to maintain that. Whereas it's much, there are clearer gender roles for men who say, well, this is part of me going back to work, therefore, I've got to prioritize this.
01:01:12
Speaker
When I talk about occupation in the paper, it's an occupational drive, it's not about work. Occupation is used in the way that occupational therapists use the term, which is those valued activities that we do. It can be roles, there can be other things that people want to do.
01:01:33
Speaker
But they have a unique way and style that people bring to their daily doings. And so what I found with the women, although there were no strong gender differences, they were saying, well, I'm a mum. I can't not do mum things. I just have to find a way to make that happen. Whereas for men, it was very much I am the worker. I have to be able to earn and support.
01:02:03
Speaker
And I have to find a way to do that, which I thought was really quite interesting, even in New Zealand's fairly non-gender biased in many ways. We've got really good role models.
01:02:20
Speaker
but there is I think it's much more complex for women in some respects because it can't give up a lot of responsibilities but I have the same token it's actually had for men because there are
01:02:34
Speaker
very strong social expectations that you will be the breadwinner. And that particularly came up in a group I ran recently with Maori males. It was an all-male group and there were four Maori men and two Pakeha men.
01:02:54
Speaker
And they were talking about their challenges in presenting as a Maori man with mana and status in the community, because there are expectations upon Maori men from the senior members of their tribe, from the Komatas. There were big expectations and they weren't able to say no, because that was just like
01:03:22
Speaker
awful, terrible, shameful. And I haven't found that strength of emotion as much amongst women in their social roles. But
01:03:41
Speaker
But when we start talking about mothering and parental duties, whereas the Maori man, it was much more my job as a Maori man is to, I must do this thing for the komato is because that's obligatory and you can't escape it.
01:04:01
Speaker
Fascinating. And that sense of who am I as a Maori man was the theme of the group really, which is how can I restore my manner, my sense of who I am. So it was again, re-occupying self, but with a stronger cultural element that I hadn't been detected as strongly in my PhD.
01:04:27
Speaker
Yeah, it's absolutely fascinating, isn't it? And so I know we've been talking around this idea of reoccupying a sense of self.
Reoccupying Self: Living Well with Pain
01:04:39
Speaker
Is there
01:04:41
Speaker
any set of guidelines still around this or is there, you know, is it such a kind of new field and everybody's case is so idiosyncratic that it has to be, you know, a multifaceted approach of supporting people to reoccupy this sense of self.
01:05:00
Speaker
I think that it starts with recognising that it is a process and that I met people when they had resolved this. So they were feeling that they were living well and they knew who they were despite their pain. And that trajectory was quite variable in time lengths because there were some who had not had pain for as long as others who'd had pain for most of their life.
01:05:29
Speaker
So they're a select group, so I'm not sure that we can directly apply them to everybody. However, being on social media as I am, I've had lots and lots of conversations with people as they're working their own way through their process of coming to terms with what's happening.
01:05:52
Speaker
And they do, you know, one of the things they they were saying is if tell me as soon as you can that and be definitive that my pain is not going to go because that gives me that stops me looking for the possible cure because the drive to go back to who I used to be my old sense of self is so strong when there's this carrot of
01:06:22
Speaker
I could be that again if this cure took all my pain away. And you know, none of our treatments for persistent pain are terribly effective. So the odds are pretty high that people are going to at least have some pain, even if it's not as intense as it is right now. But I've looked in vain for information on how clinicians convey that message to people.
01:06:52
Speaker
I've not found any research showing how we tell people you have persistent pain. So that's an area for future research. And I think it's a really important one because it comes across in a lot of the qualitative research where people say, said, and also on social media, people have said, I need to know if this is not going to go away.
01:07:20
Speaker
And there's this belief that it's no seabic to tell somebody that maybe it won't go. And I'm not convinced because we're not saying that it's not going to go. We're saying the probability is it's going to hang around for a while.
01:07:38
Speaker
And that signals to the person that if this is the way it is, then I probably need to stop this search to be who I used to be. Because there's a leading goal of those things.
01:07:55
Speaker
Sorry. Sorry. I was going to say this is where I first emailed you a few months back and was asking you about this specifically really with regards to the idea of acceptance and commitment therapy.
Balancing Acceptance and Hope
01:08:08
Speaker
The idea that if you were to accept that you have persistent pain and maybe that you will always have persistent pain, is there a danger that that could mean that people prematurely
01:08:20
Speaker
give up hope as it were and so obviously you responded to that but do you want to explain how you would how you would answer that question?
01:08:29
Speaker
Yeah, so the way that I put it to people, and this is echoed by people with lived experience online and the discourse that I have in some of the groups I belong to, where I'd say, look, we don't know whether your pain is going to go or not, but the chances are high that it's going to hang around.
01:08:51
Speaker
And what that means is that now is a really good time to learn how to get on with what's important to you. How can you be more like yourself? Because out of that, it gives permission to people to, instead of investing and putting life on hold and investing all the energy in a way to go back to my old me, they start to say, well, how can I still be me?
01:09:17
Speaker
and have this bit of wiggle room, as I describe it, to start to still do things that matter to me, which really fits, again, beautifully into ACT. And I do use the finger trap, the Chinese finger trap, with the group program, where we get people to put it on, and what happens when you get stuck with your pain, and here's this finger trap, and you try your mightiest
01:09:46
Speaker
to get out of it and all it does is grip you even harder. And that's a really nice metaphor for the efforts that people go to to get rid of their pain. They wait, they put lives on hold while they wait for the investigations, then they wait for the diagnosis, then they wait for treatment.
01:10:06
Speaker
And meantime, their relationships falling over, they're not sleeping very well, and they feel often demoralised, they're not depressed, but they're demoralised, they're frustrated and fed up.
01:10:21
Speaker
all because they're waiting for this magic wand or something that's going to bring them back to who they used to be. And the really sad thing is when you meet somebody who's had their pain for 15 years and they say, I used to be this sports person and I want to play rugby again. And they, you know, there is not a hope in hell that they'll go back to being the kind of rugby player that they used to be.
01:10:47
Speaker
They still can do rugby and get involved in rugby, but it might be in a different way. But they won't do that because it doesn't match with their belief about how it ought to be. And when you dig into that and you find out what is it about rugby that matters so much, and you find out, well, it's the comradeship, it's the excitement of the match, it's the achievement. There are lots of ways that you can still have comradeship
01:11:17
Speaker
excitement and achievement without necessarily playing rugby. You might want to get involved with rugby because you like it but there might be other ways to express those things and those are the values and it's that finding the wiggle room to allow you to feel okay about exploring other ways of becoming that person who still gets those excitement through the comradeship
01:11:46
Speaker
That's the bit that I think is where the therapy happens.
Critique of Pain Neuroscience Focus
01:11:52
Speaker
And I think, you know, we do a lot of stuff around exercise with people for chronic pain, and I think we focus very often on that it's going to reduce the pain.
01:12:05
Speaker
but if it doesn't fit that person if it's you know if they're not gym people or they don't like walking they don't have a dog um what what why else might we use movement how else can we help people use movement because we all move and can we do it in a way that fits for that person um because there's this quite narrow
01:12:33
Speaker
idea particularly in New Zealand that people will go to a gym program for their pain. Even if they've never lightened the door of a gym before and they're not going to carry it on after they've done their pain management program. Yes. And you think what a waste when they you know they might want to go kayaking or they'd prefer to walk up the top of a hill or they like to go geocaching.
01:12:58
Speaker
You know? These are all things that people can do and get that dose of what it is that they need to get from movement that don't necessarily represent the way that we might define movement. It's part of the ACT approach. Would you say that... One of the things that I think has slightly concerned me over the years of reading around it is this idea that pain neuroscience
01:13:29
Speaker
It's called pain neuroscience. You know, there's a bit of an issue in as much as it's focused on pain. And if we were to call it health neuroscience or performance neuroscience or even purposeful neuroscience or purpose-based neuroscience, something like that.
01:13:47
Speaker
It might change how we look at it as a discipline, but also how we look at people so that we are moving them more towards health in spite of their pain. We're moving more towards performance in spite of their pain or so on. I don't know if that's just me playing around with nuances, but how do you view that?
01:14:08
Speaker
So I'm not a pain neuroscience person, not because I don't do it, because I do, and I always have, way back from gate control theory. We've always included it in pain management. It's been part of multidisciplinary interprofessional pain management programs since the inception of those programs.
01:14:32
Speaker
what's different is now that it's being used as a standalone.
01:14:40
Speaker
Right, yes. And to me it fits nicely into making sense, the making sense phase. We're helping somebody name it and we're giving, so they're naming and they're beginning to predict what it means and the effect. And so we do know that information alone doesn't change behaviour, otherwise we would have no fat people and no unfit people.
01:15:06
Speaker
Yes, yes. And nobody who drinks too much. So we all know that smoking, drinking, eating too much, not exercising is really bad for health. But so being told hasn't changed our behavior. And it's the same with pain neuroscience or explaining pain and giving people some biology. It's not going to change behavior unless the person's ready.
01:15:34
Speaker
And what I know is that one of the factors in readiness to get on with life is knowing that I've got somebody on my side, I've got a reason that I want to get on and do something that matters to me and that I've made, I know what's going on and I can predict it. Those are really important things. And I think it's to use it as a standalone is actually unhelpful
01:16:04
Speaker
Because if we expect it to do everything that we want, it just can't function that way. And I also think that there's a misconception that it's going to reduce pain if you tell somebody about their neurobiology. But it doesn't because it's only going to take away the distress component.
01:16:33
Speaker
Because when we think of a pain reporting on a 0 to 10 scale or a 0 to 100 visual analog, at least a proportion of that number is about communicating to somebody else. This is how bad I'm feeling, which is distress. And if you go into ED and you say an emergency room, you say, oh, look, I've got pain. That's a three out of 10. You know, you're not going to get anything.
01:17:03
Speaker
I'm not going to get picked. But if you say it's a nine, you might. And I think where the measures used to look at PNE or whatever you like to call it have conflated this pain measure with pain behaviour.
01:17:22
Speaker
as if they're the same thing. When pain measurement on a 0-10 or a 0-100 scale is a behaviour and what we're changing is the behaviour. And it's not a very big effect and it doesn't seem to have changed disability which is actually why people start to ask for help with their pain.
01:17:45
Speaker
Most people, Ferriero wrote a beautiful paper on this and colleagues did a systematic review of the reasons that people seek care for back pain. And it's when the pain interferes with important activities. So disability. And we, if we remember that, then it's also part of the reason that people are satisfied with treatment is when they can start to do those things that they can't do and they couldn't do before.
01:18:15
Speaker
We think that it's pain intensity, but it's possibly not so peony is
01:18:24
Speaker
partial, it's a part of the package as is doing behavioral stuff and as is exercise, as is learning coping. If we put it into a framework that this person needs to make sense of what's going on and work out the impact on their daily life and then they can start thinking about
01:18:48
Speaker
Well, what am I going to do now to be me? Then maybe we can see where it fits. You can't see me, but I'm doing loads of hand gestures. I can imagine it. Brilliant. Yeah. Fantastic.
01:19:03
Speaker
Because I think we, yes, it does need to be more about health, but we also know that it's possible to change behaviour without telling somebody something. And we do this all the time. We want to change somebody's behaviour. We can just respond to them differently.
01:19:24
Speaker
And we don't have to explain. We can just make it happen. So we can, I don't know if you did this, but when I was doing my OT, we had this thing where we were training the lecturer to go to one side of the lecture theatre and not the other. Yeah. By leaning forward when he went to one side and looking forward to the other side. And he changed his behaviour. And he didn't know. We hadn't said anything.
01:19:54
Speaker
And we know that behavioural methods are really effective, but because we like words, because that's a human thing, we prefer to use words, but the more powerful part of therapy, and Johan Vlaon and colleagues have done some lovely studies illustrating this, where they deconstruct the various components of therapy, and it's the behaviour part, not the education part, that changes disability.
01:20:24
Speaker
Right. Right. Yeah.
Guided Discovery in Patient Interaction
01:20:26
Speaker
It's really interesting because it's the behavior part that people don't like doing because it's a bit scary. They'd rather talk about it than actually do it. Yes.
01:20:38
Speaker
And I think when we're looking at occupational, so we're looking at my model and people start to engage in their occupations again, the doing, by doing, they start to unpack, what do I need to learn to be able to do this? What are the strategies that I need? So it's more of an experiential process than a talky process. Yes. Yeah. Okay. And so maybe this.
01:21:05
Speaker
Yeah, exactly. So maybe this leads into, I was looking on your site and you have a list there where you're explaining that these are some of the things that you've suggested people utilize as tools over the years. And so you talk about graded exposure, self-regulation, effective communication, guided discovery,
01:21:31
Speaker
information on proposed neurobiological mechanisms, values, clarification, progressive meaningful movements, goal setting, planning, managing and progressing and positive pleasurable activities. So now obviously I can put this list in the show notes so people can have a moment to take it all in but also have it written down. But is this the kind of list of things that you would use to influence behaviour?
01:22:01
Speaker
Um, I start with
01:22:06
Speaker
identifying with the person, what's important. So that's like values clarification, if you like. So what's important in your life. And because I'm an OT, I'm going to be doing more stuff that's about, about occupational engagement. So what do you like to do, which we know as OTs is about who you are as well. And then I want to find out where are they at in terms of their stage of, you know,
01:22:35
Speaker
part of the trajectory. And if they're at the making sense phase, then we'll deal with that bit. So we'll give you some information. That's what you need. Do you have a series of, is this just through conversation where you have specific questions you ask them?
01:22:50
Speaker
No, well when I meet somebody I like to start with take me through a 24 hour day because it's pretty quickly you'll find out where the person's daily problems are. I want to know their theory, what sense are they made of everything that everybody else has told them and what they think is going on.
01:23:15
Speaker
um and I have a um there's an assessment process that I follow through on the um I think I've listed it somewhere on the blog site but it could be a while back now um so I go through that um it's a bit of a struck semi-structured interview but if I'm pushed for time it's this 24 hour day just take me through you take me through your day
01:23:41
Speaker
And as we go through, you know, what are you missing? How's that for you? What do you think? Lots of guided discovery so that I can understand where the person's coming from. Because the very first stage is trying to understand how have they got to where they've got to. Why is this person presenting in this way at this time and what's maintaining that presentation? And then we can go from there into
01:24:05
Speaker
What's your main concern? And if that person's main concern happens to be, I'm not sleeping, we'll tackle that first. Because that just makes sense. But if it's more existential, we'll start to look at what is important in your life. What would make you feel like you?
01:24:27
Speaker
And then we start to build those things in. And often, because the first thing that people drop very often are those self-care, pleasurable, fun things, social things. They'll stick to getting up and getting dressed and managing to eat them, eat and do, you know, that stuff. And they manage to stay going to work. But the fun goes and their relationships with their mates goes.
01:24:53
Speaker
So I try to build those things in because often those leisure occupations are the things that make people feel more of themselves because they express important values.
01:25:07
Speaker
So if you want to go out fishing, we'll go out fishing. If you want to play space games, video games, well, let's work out how you can do that. And then look at when you do that, what's working, what's not working, how's that working for you.
01:25:26
Speaker
And it's really a guided discovery process. And then it's saying, so I wonder if you've thought about what it's like at the end of the day. What's the short term effects? What's the good effects of this and what's the not so good? And where might this leave you? Because most people will have a clue. They might not recognize the longer term not so good effects. So sometimes I'll work with that.
01:25:51
Speaker
Um, but yeah, it's very fluid and it does. The distinction that I make between a CBT approach and act is that we don't tackle the full content. People just notice. So let's step back and notice that right now, what's your body feeling like? And what do you think your next step might be? Is it going to take you closer to being you or further away so that they can make their mind up themselves?
01:26:21
Speaker
Yeah. Yeah. So it's kind of fluid. It's not protocol driven at all. And the group program that I run is more structured. There's some requirements I need to do for ACC, as well as try and follow what what Kevin Vowles and colleagues developed in their ACT program that I have drawn on mightily because his work is fantastic.
01:26:49
Speaker
Right, yeah. And I hear he's coming back to the UK. Ah, okay. Ireland, I believe. But don't put me on that. But that would be amazing. So you'll still have Lance McCracken and Kevin Vowles in the UK. And they are my absolute favourite researchers. They're fantastic. Excellent. So something to look out for. Yeah. Yeah. Fantastic.
Supporting Patient Autonomy
01:27:13
Speaker
Well,
01:27:26
Speaker
One of the things that you mentioned to me in our email exchange was that a really interesting discussion that we as health professionals must have with ourselves is how much of the desire to help someone to get better is an ideal that we can fix them when nobody else has, or a fear that perhaps what we offer isn't actually enough.
01:27:38
Speaker
Now, one last thing, I think, because it's getting late there for you. It must be nearly bedtime at least.
01:27:48
Speaker
and so I thought that was actually perhaps something that's important for us to discuss because I think many people that end up in healthcare often there is this kind of wounded healer background and we want to help and we want to fix and we want to support but sometimes maybe that sort of can be overzealous and so do you want to elaborate on that a little bit?
01:28:16
Speaker
We are scared that we're going to fail the person because the outcome isn't what we want. And most of us have been trained to fix, which in the case of pain is get rid of the pain. Slightly different for occupational therapists, but very strong amongst medical practitioners and physios, which is that
01:28:41
Speaker
we want a remedy and we want to do it in a way that fits our model of what's important. Whereas people that we see have got lots of things going on in their lives very often and their idea of what's important might not be the same as ours.
01:29:01
Speaker
and I think we find it very hard to not do anything and just to be a witness and sometimes all we need to be is that clinician that's trustworthy enough to be a witness and sit with somebody who needs to just know that somebody knows and then to be willing to
01:29:26
Speaker
Let the person come up with the options. You know, it's a bit like when we do motivational interviewing we ask the person, what do you think might be your next best step? When we're working as OTs or physios, we'll be saying,
01:29:42
Speaker
Well, I think you should. And that's probably less effective than working with what the person can come up with themselves, even if it doesn't fit with us. And I'm kind of thinking of my man with his colored lights here, because I would never have thought that was a jolly good thing. He thinks it's marvelous.
01:30:03
Speaker
and yet he's come up with it it works well for him he's living well and somebody in his you know clinical past has been willing to say if you think that's going to work have a go why don't you experiment with it so perhaps we the way that we could flip it is to suggest to the person let's try an experiment i wonder what would happen if
01:30:31
Speaker
And if they can't come up with something themselves or even if they do, why don't we try this as an experiment and I'll be there as you work out whether it's good or bad or not. So that might be an alternative way for us to still offer help without having to drive the solution.
01:30:54
Speaker
Yeah, yeah, perfect. Beautiful stuff. Well, this is such a huge and exciting topic. I know we could carry on talking for a long time and I've got several things down, which I kind of would like to talk to you about a bit.
01:31:10
Speaker
I know you did say before we started that you were in the mood for a chat so that's fantastic and it has been amazing I think certainly for me it's created a lot more clarity in both in your work but also in how important it is to get that process right you know in terms of getting the making sense first and I think I was probably a bit more focused on the idea of
01:31:34
Speaker
actually finding a bigger goal and a life purpose and this kind of thing without perhaps as much recognition of the immediate here and now challenges that the person is facing and trying to get them to focus beyond that, which obviously, as you say, it's a good idea, but it's not feasible in many instances when they're at that making sense stage. So that's been great for me to pick up on.
01:32:03
Speaker
I'll be really interested to see if clinicians start to apply this to see what the response is from the people that they're working with because the response I've had from people who are living with pain is that that seems to be more acceptable for them.
01:32:24
Speaker
And especially that being able to predict in the here and now, you know, over today, over next week, what's the effect of this pain on my energy levels and what I can and can't do and not changing anything at that point because
01:32:42
Speaker
except for improving sleep, improving diet and probably invoking some rest and some fun because when we put those little everyday short term things in that seems to build
01:33:00
Speaker
I don't know, it builds momentum towards giving some breathing space so the person can think about, well, if this is how it is, I do need to get on with my life. And what might that look like? And it validates the concerns too.
01:33:16
Speaker
Yes, yes, exactly. One of the models we talk about in the Czech system is the idea that each individual has their own sort of set of inner physicians that they can consult with. And so you've got Dr. Diet, Dr. Quiet, Dr. Happiness and Dr. Movement. And so on any given day, at any given moment, you can
01:33:37
Speaker
have a bit of introspective time and say now which of these physicians do I need to spend more time with today? Do I need to tidy up my diet a little bit or do I need to spend some time doing things that make me happy or have I not moved as much as I should do just recently or I'd like to just recently? And then of course quiet as well as to rest and to sleep and to put your feet up rather than be at the cold face the whole time.
01:34:03
Speaker
or even going for a walk where I don't have to think about anything. I can just let my mind out. Well, that's it. That's it. Yeah, exactly. The other doctor I'd recommend is Dr. Purpose. What's my purpose? Am I being purposeful today? Why am I doing these things? And I guess that's the bigger, I think people who are in that first phase of making sense often lose their sense of purpose because
01:34:32
Speaker
Your immediate purpose is, I need to know what's wrong. I need to know what the impact's going to be. And I need to be able to sleep and just look after my basic needs. And yet, there's always this drive in humans to be purposeful about what they do. And so we could give them that mission at the moment,
01:34:54
Speaker
is to find out this name, to be your own expert on what happens with your pain and to be your expert on what makes you feel settled for now. Maybe that's another way of viewing it. I don't know. Yeah, absolutely. I love what you've talked about.
01:35:13
Speaker
seems to fit very neatly with Maslow's concepts of his hierarchy of needs and getting those physiological needs met and then, you know, developing a sense of self and companionship and also the ultimately of the kind of self-actualization and a purpose for being. I know Maslow's work is now quite old, but does it fit with your understanding of...
01:35:40
Speaker
I think people can temporarily override certain things in that hierarchy because purpose is something that's innate in humans. People don't generally do stuff for no reason. They're either meeting somebody else's expectations or their own expectations.
01:36:01
Speaker
And so the purpose is part of who we are as humans, is this values-based thing. Psychology talks about the need to relate, the need to be able to make your own autonomous decisions.
01:36:19
Speaker
I can't remember the other ones but I think those are also driven the innate goals that help us to flourish and I think as an OT I'd be looking at what are the doing things that matter
01:36:35
Speaker
that help you feel like yourself. And for me, you know, one of those things is creating, I've got to be creating something, whether it's drawing, photography, silversmithing, gardening, whatever, but that drive has to be met for me to feel healthy. And maybe there are other things for other people that equally
01:37:00
Speaker
crucial to their sense of self and well-being. And sometimes we just need to help that person identify what that is. And so I ask, you know, what would you be doing if pain was less of a problem for you? That's the trigger to working out what it is that they really want to be doing. And that's awesome, because that gives you values.
01:37:25
Speaker
Definitely, yeah, fantastic. Alright, well Bronnie, look, I'm going to let you get off to bed and thank you so much for your time today. Like I say, I could keep going for a long time, I'm sure. But now, if people wanted to find out more about your work, I know obviously you have your blog, where would you direct them to?
01:37:47
Speaker
I would go probably to my blog. I don't have very many publications because I'm a really, really lousy writer and I'm a teacher. And so I don't have time to do much academic writing. I've said don't agree with you that you're a lousy writer. I'm writing on
01:38:09
Speaker
on social media is, so there's the social media exploring pain research and meaning group, which is the largest group. I think we've got 22,000 members. Yeah, that's amazing. We've got my healthskills.co.nz blog and that's, I've been going since 2007. So it's quite a lot of writing in there and I blog once a week.
01:38:37
Speaker
So there's just a lot of stuff there. And people are most welcome to contact me via the blog or via Facebook. Otherwise, I'm always reachable through University of Otago, where I'm listed under the Christchurch campus as Bronwyn Lennox Thompson in the department of orthopedic surgery, would you believe?
01:39:05
Speaker
Wow, fantastic. And do you run courses at all? I do, yep. So I'm running one for the San Diego Pain Summit on ACT, a two-day workshop that's in February. I'm running one this weekend, actually, a CBT course for physiotherapists in Wellington, where we have 50 people enrolled in a waiting list, which is really exciting. Wow, excellent.
01:39:32
Speaker
Yeah, and so I can do, I have done sessions on graded exposure, on my research work, on motivational interviewing, primarily around sort of psychosocial and communication, because I think communication's that skill that you cover in your first year of training, and then you very rarely go back to.
01:39:56
Speaker
And really, a lot of CBT and ACT is actually skillful use of communication. Rather than saying we're doing psychotherapy, we're just being really good at asking questions and helping people join the dots themselves. And that means that it's not as much hard work for us.
01:40:17
Speaker
Yeah fantastic, fantastic. Well thank you so much for your time and I'm sure we're gonna have more discussions down the line but yes thanks for all your hard work and all your insights. It's been really fascinating and I'm sure it's going to help not just a lot of our listeners but also their clients and I don't know whether we're allowed to call them patients from what you were saying. That was another thing I was going to ask you about.
01:40:43
Speaker
I prefer to use people, but I keep on eating. They are people mainly. Yes, exactly. That's why they fall into the old habits. Yes, for sure, for sure. Brilliant. Okay. Well, thank you very much, Bronnie. Okay, you're welcome. I appreciate it. Take care. Thank you. You're welcome. Bye-bye.
01:41:05
Speaker
So as you can tell by her enthusiasm and her depth of responses, Bronnie is a true master of her craft. And what's really great about Bronnie is she's still exploring, using a mix of her interactions with those experiencing pain through social media, through colleagues internationally and with the people she works with locally in New Zealand.
01:41:23
Speaker
In March 2020, I'm heading out to New Zealand too to put on a two-day seminar in Auckland called 2020 Vision, putting persistent pain behind us in the next decade. Now, the apparent irony in the name after a podcast like this, putting persistent pain behind us, may not be lost on you. However, all I can share at this stage is that there is more than meets the eye, and the model I'll be presenting will help to make sense of how we can truly put persistent pain behind us.
01:41:51
Speaker
If you're nearby, come and join us, either at the event in Auckland on March 7th or 8th, or at the event in Sydney on March 14th and 15th. To secure your place or get more information, please head over to MattWarden.com. Who knows, we might even entice Brawny to come along and make a guest appearance. Thanks for listening. If you enjoyed it, found it useful, or know someone who will, please share it. See you at the next show.