Well, I wasn’t planning on publishing a blog on this topic until later, but it seems timely in light of recently published research (here.) Articles, books, courses, and even certificates/credentials, all exist surrounding the education of patients with persistent pain. I understand the noble objective of reducing catastrophic thinking, pain intensity, improved agency, and reduced disability through education. And I strive for these goals in my care model as well. But I do challenge the idea that because we think we are imparting objective information, that it will convince someone of something different. Patients hold deep beliefs about their pain. We assume that presenting facts will change someone’s mind. They don’t. I don’t think we consider the gravity of what we say to our patient’s experiencing persistent pain. It may seem like we are delivering unbiased education, but the reality is that it can be perceived as an affront to their suffering. It can be viewed as dismissive to what they are telling us their experience is. It’s like trying to change the views of someone whose political beliefs are opposite of yours. Your attempts at convincing them only deepen their opposing thoughts. When it comes to beliefs, facts don’t matter. Scientific data is insufficient to convince someone of a differing belief. There is significant scientific inquiry into how beliefs change. Emotion and value processing are integral to the process.
“To make a change we must tap into those motives, presenting information in a frame that emphasizes common beliefs, triggers hope and expands people's sense of agency.” -Dr. Tali Sharot
Read more about her lab and research (here.)
A recent patient was very focused on wanting another MRI to see if “xyz” was still going on in her knee. It was a topic she brought up every session. Arguing, I mean educating, her would only deepen her resolve that she wanted another MRI. So I didn’t try to. Instead I focused on the huge amount of ability she had gained in the previous month compared to years of disability following an injury. I then had an even better discussion of what vocation might look like for her and how we could help her feel more capable to perform those tasks. This is huge. Abandoned life roles are now back on the table. That is more important, than me convincing her that she doesn’t need another MRI. If she gets another MRI and it shows no change from prior reports, I don’t know that it will increase fear. It might. It also might not. What I do know is that she’s looking for opportunities because she feels ready to do so. She is self managing better, feeling better, and doing more. I didn’t need to “educate” her. I helped her to experience it.
In earlier blogs I’ve discussed pain as maladaptive neuroplasticity (here) and that we want to use strategies that foster neuroplastic change away from persistent pain (some strategies here & here.) I think the notion of didactic education on pain topics ignores the importance of the implicit process of neuroplasticity. How does explicit education achieve this? I don’t think it does. Dr. Sharot notes that we asymmetrically value information and thus weight of information presented to us differently. I think my messaging is better received when I facilitate a patient’s self discovery. Helping them experience “I can move and it doesn’t have to have feel bad” even if the movement is far away from the painful site, or is a tiny movement. Meet them were they are. It’s not time to “poke the bear.” In fact, it is the opposite. It is to help change their implicit understanding, through experience, in the presence of all the other factors that still exist. My message to patients is “Let’s try something different, if it bothers you, we will stop, you are in control.” I don’t attempt this without strategies for self management being established first. I want to reinforce that if a flare up happens, they have tools to help reduce it.
My approach consists of shifting focus from a pain score to an awareness and mindfulness of tolerance, helping patients tune in to baseline versus flare-up to understand that many factors can influence their symptoms. And that it is therefore possible to impact them. Maybe we go for a walk together, and even though they experienced pain, they also experienced ability they may not have known they had. I tell them how many minutes they tolerated, or what distance they achieved. If the activity flares them up, then we know to grade it down. It’s experiential reinforcement of the message I want to impart. This is valuable for changing beliefs, neuroplastic change and predictive processing. Once a person expresses an observed outcome that is of a theme that would be more helpful to them, then I use education to reinforce the discovery. At that juncture, information can help strengthen the belief. A common moment when I do this, is when a strategy has been useful in any way. If a strategy has led to feeling any sensation, that is not suffering, I want to emphasis it. I reflect the thought back “That is great that it helped you feel less stressed” or whatever the feeling was that they noted. And then I suggest purposeful dosing of that thing.
I can influence context throughout the entire encounter. I impart messages of tolerance, pacing, “sore but safe”, “hurt not harm” without explicitly saying so: “how do you feel, can you keep going or do you need a break?” I am consistent in my messaging every session when an opportunity arises to highlight what they’ve demonstrated. Education is vital, but it doesn’t have to be a curriculum and it shouldn’t be confrontational. It’s about the patient proving it to themselves, not me trying to convince them. Implicit learning instead of explicit. Followed by support and strengthening of the updated belief.
With a perspective of pain that is rooted in neuroplasticity and sensory and predictive processing, I take some cues regarding patient learning from the body of knowledge of motor learning. The learning comes from repetition and implicit feedback is better than explicit.
Every session I review flare ups, what preceded them, and how strategies for self management impacted their symptoms. Thereby reinforcing the idea that pain is not random, can fluctuate with many influences, and different things the patient does (or thinks) can impact it.
Education is vital with patient's experiencing persistent pain. But every patient doesn't necessarily need a run down of everything you've ever read and every course you've ever taken. Dosing and quantity are important too. If in the patient's narrative, I hear that they believe they've been told "it's all in their head", I’m not going to talk about the brain and danger messaging. I take a generalized approach to pain related education. “Some things help you feel better, and some don’t feel so good. Let’s work to find what helps you to feel better and use it to help you manage your symptoms better.”
This is challenging stuff. You’re not a bad educator if you can’t seem to get the message of the “curriculum” right. Try helping them experience it instead.
Caneiro, J., O’Sullivan, P., Smith, A., Moseley, G., & Lipp, O. (2017). Implicit evaluations and physiological threat responses in people with persistent low back pain and fear of bending. Scandinavian Journal Of Pain, 17(1), 355-366. doi: 10.1016/j.sjpain.2017.09.012
Costa, D. (2016). Changing pain-related knowledge may or may not reduce pain and improve function through changes in catastrophising. PAIN, 157(9), 2141-2142. doi: 10.1097/j.pain.0000000000000617
Edelson, M., Dudai, Y., Dolan, R., & Sharot, T. (2014). Brain Substrates of Recovery from Misleading Influence. Journal Of Neuroscience, 34(23), 7744-7753. doi: 10.1523/jneurosci.4720-13.2014
Lee, H., McAuley, J., Hübscher, M., Kamper, S., Traeger, A., & Moseley, G. (2016). Does changing pain-related knowledge reduce pain and improve function through changes in catastrophizing?. PAIN, 157(4), 922-930. doi: 10.1097/j.pain.0000000000000472
Sharot, T., & Garrett, N. (2016). Forming Beliefs: Why Valence Matters. Trends In Cognitive Sciences, 20(1), 25-33. doi: 10.1016/j.tics.2015.11.002
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