Anything can work some of the time. Nothing works all of the time.
This phrase works really well to illustrate the complexity of working with pain. Pain is dependant on multiple, diverse, interacting variables. Pain is a perception due to the interplay of biological, psychological and social influences. Always. For an excellent history of the biopsychosocial model see Cocks 2014.
Leading pain scientists and educators Moseley and Butler 2017 state pain emerges when Danger In Me (DIMs) messages exceed Safety In Me (SIMs) messages. And, importantly, DIMs and SIMs can hide in hard to find places.
The upside of the complexity of pain is that we can pull on many different threads to influence pain. If we are lucky, tugging in the right way, on the right thread, at the right time, can unravel the whole edifice of a pain event. Anything that increases the sense of safety can generate good news inside the person and down-regulate the alarm system of pain.
The upside of the complexity of pain is that we can pull on many different threads to influence pain.
Not enough people working with pain understand the importance of overwhelming experiences when trying to find safety. The key to creating safety is understanding trauma. The key to unlocking trauma is coming out of dissociation into a rich, nuanced experience of connection to the body, Porges 2017 and van der Kolk 2014.
We need to be constantly creative to keep feeding good news to the threat detection systems that assess messages of danger and safety. The body’s control and coordinating systems – the nervous, immune and endocrine systems – grow with variety, Merzenich 2013. There is a place for simple routines and ritual, but, habitual, rigid ways of being tend to limit our choices. Fixed habits quickly stop generating good news and quickly stop being a source of growth.
‘Anything can work some of the time, nothing works all of the time’ helps us be cautious in attributing a change in pain to the specific intervention of the therapist. If we find a way of treating pain that works for us, as individuals or as therapists, be careful of extending that experience to whole communities. In the history of treating pain there have been lots of false dawns, over claiming and optimistic thinking.
For example, in my chiropractic study many models of treating the spine were offered as fiercely defended, universal truths. But not many have stood the test of time. Indeed, the whole paradigm of manipulation of the spine would appear to be deeply flawed, Ernst and Canter 2006. ‘Often our theory fails at depths we seldom visit’ according to Lorimer Moseley 2019. There is space for some deep philosophical house cleaning around pain myths; pain is really strange, Haines 2015.
A stimulus that is perceived as safe, and, that makes sense to the client and therapist, will be helpful, somehow.
Many therapies work primarily because they are a novel stimulus to a stuck organism. A stimulus that is perceived as safe, and, that makes sense to the client and therapist, will be helpful, somehow. Therapies often work in-spite of the underlying conceptual paradigm of the therapist, Meakins 2017.
Modalities based on structural models (e.g. ‘align the spine’), or energy models (e.g. ‘vibrate in a gong bath’), or talking models (e.g. ‘express the emotion underlying the pain’), or surgery ( e.g. ‘repair the tear to heal the pain’) are too simple and often extrapolate further that is wise from a few successes.
Changing concepts around pain is a deeply effective model. The metaphors and stories we use to frame pain are important. Beware of ‘thought viruses’ that subtly undermine your confidence to move. Avoid models that imply you are a permanently damaged, broken machine, Setchell et al. 2017. Tragically, these are the unintended messages absorbed by clients in many structural musculoskeletal treatments; how scary is it to be told one leg is shorter than the other?
At the other end of the scale, also be careful of models that focus solely on changing beliefs, often with added energy and spirit. Bruce Lipton offers ‘Your body is an illusion’, Deepak Chopra states ‘The physical body is a fiction’, Byron Katy suggests you go on a ‘No Body Intensive’. There is huge potential that these messages end up confusing people stuck in dissociation.
Just because we can influence pain through shifting constructs and emotions, it does not follow that there are only beliefs.
Changing concepts and beliefs does not remove the need to engage the body. Or, indeed, the need to work with any other elements of the biopsychosocial model, not least social injustice. Just because we can influence pain through shifting constructs and emotions, it does not follow that there are only beliefs. It’s hard not to see the ‘no body’ models as radical oversimplifications resulting from the teachers idealism. Their spiritual beliefs seem to come at the expense of connection to the body and recognising wider forces of disempowerment in a person’s life.
The best science currently seems to point towards the following:
Do keep moving
Keep moving in new and meaningful ways. Be playful, challenge yourself slowly and allow plenty of recovery time. (For inspiration try Hargrove 2019).
Do keep feeling
Learn to be with intense sensations without getting overwhelmed. Explore all of the concepts you apply to all of the feeling states inside you. Try and tell yourself more elegant and beautiful stories in response to those feeling states. (Barrett 2017 is a great guide to feeling).
Do understand pain as a protective feeling
Reframe pain as protective feeling rather than an accurate measure of tissues damage. Anything that promotes safety can be helpful. Know that safety evolves and it includes more and more experiences over time. (Moseley and Butler updated their classic Explain Pain book in 2017, they are great guides to pain science.)
Do be creative when working with pain
Don’t focus on only one element of the biopsychosocial model. Explore widely to find your danger messages and thought viruses. Do include poverty, racism, sexism, social injustice, in all its forms, when appreciating the loads you are carrying (Purser 2019 is a good start on changing society rather than the individual). If what you have been doing for years is not working, try something different, get help to find your creativity.
If what you have been doing for years is not working, try something different, get help to find your creativity.
- Cocks T (2018) Everything old is new again, on a history of the ‘biopsychosocial model’ noijam.com http://bit.ly/noijam-bps
- Barrett LF (2017) How Emotions Are Made. The Secret Life of the Brain. London: Macmillan. See also http://bit.ly/2zBjzot
- Ernst E and P H Canter PH (2006) A systematic review of systematic reviews of spinal manipulation. J R Soc Med. 2006 Apr; 99(4): 192–196.
- Haines S (2015) Pain Is Really Strange. London: Jessica Kingsley Publishers.
- Hargrove T (2019) Playing With Movement: How to Explore the Many Dimensions of Physical Health and Performance. Better Movement.
- Meakins A (2017) Why treatments appear to work… The Sports Physio http://bit.ly/2MEUMey
- Merzenich M (2013) Soft-Wired. Parnassus Publishing.
- Moseley GL (2019) ‘Often our theory fails at depths we seldom visit’ NOIGroup http://bit.ly/2Fu6p2f
- Moseley GL and Butler DS (2017) Explain Pain Supercharged. NOIGroup. For an intro to DIMs and SIMs try https://noijam.com/2015/03/12/dim-sims/
- Porges S (2017) The Pocket Guide to the Polyvagal Theory: The Transformative Power of Feeling Safe. Norton Series on Interpersonal Neurobiology.
- Purser R (2019) The mindfulness conspiracy. The Guardian. http://bit.ly/2Fg7JWg
- Setchell et al. (2017) Individuals’ explanations for their persistent or recurrent low back pain: a cross-sectional survey. BMC Musculoskelet Disord 18 (2017-11-29 19:41:31) 466. For great discussion see http://bit.ly/2ADWHsa
- Van Der Kolk B (2014) The Body Keeps The Score: Brain, mind, and body in the healing of trauma. New York, Viking.