backfired attempt to offer a different perspective on pain

[Adam]

Below is an email tread (chronologically set from top to bottom) I had yesterday with one of my clients. But first my thoughts about it...

This spun out of control quickly. After being a part of the BBM community and attending the 2 day seminar I have learned a lot about the biopsycosocial model of pain. I don't preach this info with reckless abandon, however when an opportunity presents itself (especially with one of my clients) I like to open the door to spread the good word I have learned.
I was bothered by this last night as I reread the thread. It's obvious, by the outcome (her last reply) that I had taken a misstep. I think what I have learned from this situation is that I hadn't built up enough rapport with her. I'm also questioning if the link I provided was appropriate for her and her current understanding of where pain comes from. This feels like a slippery slope. Trying to stop silly bs and getting clients to think about re framing their interpretation on where pain comes from. I would love to know your thoughts on it so that I can be more effective in the future.

1st email from my client:

The last we trained was 12/20. I had pretty bad low back pain until the 25th. I used a heating pad daily and ibuprofen and advil pm at night
It has lightened up enough for me to do cardio only.
I know what my back feels like when it is ready to go out of alignment. While I did hire you I have no intention of throwing out my back.
After what I have endured this past year I don't need any more issues.
Yes, I want to be healthier and stronger but we need a happy medium. Doesn't make sense to not be able to exercise for days on end.

My response to above:

I’m sorry to hear of your back pain. What do you think caused your pain? My #1 goal is to help you keep training as a sustainable part of your life style. Days / weeks on end not training would be reserved for rare cases (generally a Dr.’s orders). That being said there are ways to manage your symptoms to help improve things. There is rarely a case where movement (modified if needed) is not productive in relieving symptoms of back pain. I’ll never suggest that a client “grind” thru a workout without modifying for pain. Pain is very complex. Here is a linkhttps://www.barbellmedicine.com/the-...in-comes-from/ (that includes other links that could be very helpful) that may interest you. I’m not suggesting pain isn’t real, however as research shows it does not manifest itself simply because there is tissue damage or a biomechanical issue. Dr Austin Baraki (the author) is an MD and a strength and conditioning coach that has done a lot of research on the issue of nonspecific back pain. He explains it in an easy to understand way. From what I understand of you thru our past conversations you may be interested in understanding more relating to this topic.
Let me know if you have any questions about it if you read / listen to the links in the article.

Her response to above:

Ever since I bulged my disc between L4 and L5, that area has been sensitive. I assume it was aggravated by lunges, squats and dead lifts. While I don't have much discomfort doing the movement, the next day is a different story. No, I don't have doctors orders to stop exercising. Common sense and knowing how my body has operated in the past tells me when to back off.
I refuse to go through that level of pain again. I lost almost 3 weeks of work and many, many months of rehab.
I am open to trying different things. I glanced over the article but honestly got annoyed as I am not imagining my pain. I am not imagining what I have been through.

My response:

I am not at all suggesting that you are imagining pain! And if you chose to dig a little deeper with an open mind regarding the topic, it may be helpful for you. That is all I was looking to do, offer a point of view and some evidence based research / information. My only intention is to be helpful! My apologies if you took it any other way.
Of course, you are the only one in charge of what you think is best. I merely wanted to offer a different perspective. I want you to feel confident exercising and I want it to be something that you continue to do for the rest of your life!
We can certainly adjust the programming to minimize any pain you may have. I’m not tied to any exercises, just the concept that you keep moving

Her response:

Your different perspective is not clear to me at all. I have every intention of being open minded but the delivery of information is either confusing or degrading.
I am pretty annoyed with our conversations

My response:

My apologies again, Julie! I am apparently not doing a very good job of being helpful or supportive. Would you be open to talking on the phone at some point tonight or tomorrow?

Her response:

Thanks Adam.
At the moment, I am not open to talking.
Another time.

[Matthew Rupiper, PT]

Hi Adam,

I smiled as I read your exchange. Having spent just shy of a decade trying my best implementing a biopsychosocial approach in the clinic, I've been where you are and have heard this many times from other clinicians. Having listened to Lorimer Moseley, David Butler, Adriaan Louws' speak on the topic, so have they. They joke about it frequently.

I'll keep my feedback short as I'm sure you're looking for Derek and Michael's response.

"I don't preach this info with reckless abandon, however when an opportunity presents itself (especially with one of my clients) I like to open the door to spread the good word I have learned."

Reading her responses, I didn't see an open door to the topic. Her first email was a closed door to anything but empathy and some strategic re-assurance. Her response to your link is a cookie cutter biomedical perspective...Tread lightly here...she's unhappy and annoyed...you kept going down the rabbit hole of conflict...hard to dig out of this hole...

I agree with you. I think you needed more time to build rapport, consistency, her confidence in you as a trainer. I don't think it was time to pull out anything that mentions a brain. The link you sent is a good one...when used with the right person at the right time.

My approach based on her initial email:

Hi Mrs. Doe,
I'm sorry this occurred and I agree, feeling this way for multiple days is not our goal. We can certainly adjust the programming to minimize any pain you may have at our next session. (last part were your words on your second response). I look forward to our next session. Thanks for your honesty. That'll help immensely moving forward.

No pain science, no brains. Just simple re-assurance, sorry and lets work together next time to make this right.

I look forward to other's feedback on this topic. Thanks for sharing this tough encounter. It is really tough for people to share cases where they don't succeed. Kudos to you!

[Austin Baraki]

Sorry about this difficult exchange. I agree with Matthew, she didn't seem nearly as "open minded" as she thought.

The best way to start these replies is to first ask the person if they're interested in learning more. You can sometimes frame it in a really positive way, like "there's a lot of exciting research coming out that has given us the tools to better help people in pain. would you like to learn more about it?"

And as for a resource, I like http://tamethebeast.org as a lay-friendly introductory resource on the topic, as well as some of Moseley's other content available on YouTube.

[Adam]

Thank you both for your feedback! Terrific perspective, I really value your inputs. I’m in this game to learn and this was certainly a learning experience. In hind sight, I agree completely with both of your assessments. I did have the opportunity to sit down face to face with her today, as she did follow up with wanting to discuss it further. It went well, I believe that she now knows that my intention was to help. I admitted to her that I took a misstep. I had the opportunity in that conversation to discuss broadly about the biopsycosocial model ( since she did ask for me to clarify what I was trying to convey. I didnt get into much detail at all, I just tried to explain that there is more out there regarding pain than what most people perceive. We will be continuing to train together and we discussed a strategy of identifying what may have caused her pain following the work out. I believe we are now both on the same page moving forward. My plan is to be more of an active listener and to handle these situations more delicately as we move forward. She teared up today regarding her pain and what she has been thru and opened up that she has not been very open to others about her experience regarding pain. Every failure is an opportunity to learn and move forward, and with this forum and your feedback on the raw details of my situation I feel empowered to proceed in my efforts more delicately in the future. Thanks Matthew and Austin.

[Eric Lagoy]

Hi Adam,

I think we all can applaud your transparency here in an effort to learn from this situation. I agree with what Matt has suggested and will also keep my response brief to allow Derek/Mike to chime in, but I thought I would offer some additional feedback, as this situation is all too common for me as well.

In healthcare we often talk about "therapeutic alliance". Simply put, therapeutic alliance occurs when:

1. therapist and patient agree on interventions
2. therapist and patient agree on goals
3. therapist and patient have a solid bond

If we take this concept and apply it to your situation here, we can observe a few things.

1. First, you already admit to not perhaps having the best rapport with this client.
2. Next, it seems goals are not exactly on the same page as well. Perhaps you feel she hired you to maximize her health/strength/fitness, but maybe she may have hired you in hopes to build strength to prevent
pain, stay in alignment, etc. I'm totally guessing here.
3. For sure, agreement on interventions (in this case, your programming), is not on the same page. You might feel that your programming, with appropriate modifications, will put her in a position to achieve the
desired goals (which brings us back to point 2). But she seems to think your programming is too aggressive, given her medical history, and this was amplified through the negative outcome from one of the
training sessions.

I bring up this concept of therapeutic alliance because it will always be a challenge to create change in belief structures (e.g. educating her on her source of pain), without having these 3 criteria met first. In fact, in rehab a strong therapeutic alliance has been show to be associated with better outcomes. Perhaps in the future, if you are considering attempting to change belief structure regarding pain with a client, you can double check that you have strong therapeutic alliance before proceeding.

Other lessons learned, more from experience than research here, it can be even more challenging to change belief structure during a flare up or set-back. Do what you can do build that rapport, and when they start feeling better, you can sprinkle in content from the BSP model as it naturally presents itself during conversations. Then, when/if a flare up or set-back occurs, you already have some seeds planted to handle these conversations a bit easier while staying within your scope.

Hope that helps. Great conversations and curious to here others jump in on this one!

[Adam]

Thank you Eric. This is helpful. I appreciate you taking the time to explain the therapeutic alliance. I’ll take time to practice it more diligently in the future for sure.

[Adam]

Sorry about this difficult exchange. I agree with Matthew, she didn't seem nearly as "open minded" as she thought.

The best way to start these replies is to first ask the person if they're interested in learning more. You can sometimes frame it in a really positive way, like "there's a lot of exciting research coming out that has given us the tools to better help people in pain. would you like to learn more about it?"

And as for a resource, I like http://tamethebeast.org as a lay-friendly introductory resource on the topic, as well as some of Moseley's other content available on YouTube.

After watching the video link you sent I searched for more from him on YouTube and found a video I watched from Moseley a few months ago, https://youtu.be/gwd-wLdIHjs. I loved this video and have referenced it to some of my clients in the past. I found it very helpful!

[jab]

Hi Adam,

thanks for sharing your story. I dont know whether you actually intentionally named your thread like you named it.

There is a thing called "the backfire effect". _When i read your initial post, i was thinking: Oh boy, here we come - backfire effect. Not so sure now, since your client has not shut the door, which i would have expected. Anyway, still wanna share, maybe you are just interested in it and maybe it might help you in the future:

https://rationalwiki.org/wiki/Backfire_effect

Quite a famous study about the backfire effect (cant comment on how accepted / good it is):

http://pediatrics.aappublications.org/content/pediatrics/early/2014/02/25/peds.2013-2365.full.pdf

Question is, if we cant argue with facts / science / research papers because of the backfire effect, how can we have an open discussion / positive debate about ANY topic?

Disclaimer: If you are religious, or anyone who reads the following, it is not my intention to bash religion. I just read the book and watched the videos for educational purposes. Since i think this method can be used in any similar situation and is not limited to religion, i think it is a good recommendation:

So one way might be "street epistemology". The website itself says: Street Epistemology is a conversational tool that helps people reflect on the reliability of the methods used to arrive at their deeply-held beliefs. (NOT limited to religion)

It derived from a book:

https://www.amazon.com/Manual-Creating-Atheists-Peter-Boghossian-ebook/dp/B00LKBT0MC/ref=sr_1_fkmr0_2?ie=UTF8&qid=1546628127&sr=8-2-fkmr0&keywords=how+to+produce+atheists

The most famous guy using this approach is "Anthony Magnabosco", he has a youtube channel:

https://www.youtube.com/user/magnabosco210

Again, i dont particularly like the title of the book NOR that anthony uses the "method" mostly in a setting where he talks about religion. The method can be used with ANY topic where someone thinks something (what he believes) is true. The goal is to find out WHY he thinks what he believes is true. Most of the time they dont come to the conclusion that "the scientific method" was the main driver to come to that conclusion.

Hope this helps

[Adam]

Hi Jab, Thanks for sharing your thoughts. It was not my intention to name the thread that in regards to the link you provided. I meant it more like “well that backfired in my face”. I’m happy to say that the situation has been mended with my client (I hope, although I will be treading lightly for a while). Thanks for the other links as well. I’ll have to check them out

[Corey]

There is a thing called "the backfire effect". _When i read your initial post, i was thinking: Oh boy, here we come - backfire effect. Not so sure now, since your client has not shut the door, which i would have expected. Anyway, still wanna share, maybe you are just interested in it and maybe it might help you in the future:

https://rationalwiki.org/wiki/Backfire_effect

FYI: The backfire effect has recently been disproven. Paper: https://papers.ssrn.com/sol3/papers....act_id=2819073 and a podcast if that's your thing: https://youarenotsosmart.com/2018/01...ect-part-four/

This is a fascinating thread that has me thinking about many conversations/situations, not just relating to pain. Thanks!

[Adam]

Corey, glad you may find this thread helpful. And thanks for the link and your input

[jab]

FYI: The backfire effect has recently been disproven. Paper: https://papers.ssrn.com/sol3/papers....act_id=2819073 and a podcast if that's your thing: https://youarenotsosmart.com/2018/01...ect-part-four/

This is a fascinating thread that has me thinking about many conversations/situations, not just relating to pain. Thanks!

Oh, brilliant! Thank you soo much for the links! Will look at it tmr and share with at least 30-40 ppl . I am so stoked, thanks again

[Matthew Rupiper, PT]

For those with back pain I like this video from Doc Mike Evans. It doesn't talk about the brain and is very non threatening and re-assuring.

https://www.youtube.com/watch?v=BOjTegn9RuY&t=77s

Another video that I've had patients refer to when things are more persistent (chronic)

https://www.youtube.com/watch?v=RWMKucuejIs

[Dhruv4]

Just came to this Article after the Q&A video and respect dude, I would’ve gave up on the client or most likely unintentionally said something inflammatory.
When Austin said the words back fire and effect it got me aroused not gonna lie, I personally experienced it when I first introduced fairly strong literature to PTs that I worked with that what they were doing and saying to PTs was incorrect and have no doubt that as I get further along in my Education and career that it will occur again.
But props to you.

[Adam]

Thanks Dhruv4,. The scenario was a great teaching point for my coaching career. I'm thankful for the BBM crew and community to help me realize what I may have missed and how it got to where it went.

[JBDB35]

I have nothing insightful to offer in regards to criticism or advice Adam, but just wanted to chime in and say that I really appreciate you sharing this experience with all of us. As a future clinician, I found it incredibly interesting and thought-provoking to see how some of our attempts to help patients can go awry, and I'm glad you were able to get a second chance with the patient to help express yourself and rebuild that therapeutic alliance that Eric mentioned.

[Adam]

Thanks JBDB35, I appreciate you saying that. I'm glad I was able to mend the relationship as well. A little less ego and a little more humility went a long way when it came to rebuilding.