| |At this point, we have elicited a measurable prediction and ran behavioral experiments to refute it. The next step is to build confidence in the results. This step is both simple and very difficult. It’s simple because we are essentially going to repeat the experiments, altering them based on the continual updating of the prediction. It’s difficult because momentum is a powerful thing. A single refutation is rarely enough to alter the course in a lasting way. We’ve typically thought of this stage as a gradual progression, and rightfully so. It usually takes a graded form. But, there are suggestions that it doesn’t need to be. It can jump around instead of strictly climbing a hierarchy. In the Craske review on maximizing exposure based care, they mention letting the patient decide what is important to them to deal with next and letting that guide the order of progression as opposed to some strict hierarchy.
An example of what this stage may look like:
Initial prediction: Bending forward OR lifting more than 20 lbs will damage the back.
Behavioral experiment: Demonstration of the patient getting into trunk flexion in other positions, like quadruped, leading to squatting position that raises into a forward bent position, followed by forward bending. They repeat many repetitions that day and over the next few days, continuing to strengthen confidence that the finding was not by chance.
New prediction: Bending forward AND lift 20 lbs will damage the back
Behavioral experiment: Demonstration of the patient carrying 50# in an upright position (confront with strength). Patient demonstrating the ability to squat 100 lbs through a partial range (confront with strength). Patient starts off seated holding 20 lbs and sets it on the floor. They are then shown how the back is being subjected to the same forces during this maneuver. They then lift 20 lbs. from a chair. They repeat many repetitions that day and over the next few days, continuing to strengthen confidence that the finding was not by chance.
Some important things to note here.
First is that the prediction is not staying static. It gets updated based on the new information. We have a role here in continuing to elicit the changes in the predictions in a measurable way.
Next, the repeating of the process allows a building of confidence in the trustworthiness of the results.
Also, it is likely that there will be occasional times that the result is not good. The more confidence and experience that is gained with achieving the refutation result, the less likely they will trust this negative result!
Repeat the process in varying contexts. This builds confidence that the result is not bound to one particular set of circumstances.
What is very cool is that we can teach this process of “predict -> test -> repeat” as a skill to our patients. We can help them use their creativity to come up with ways to test and progress on their own.
In my last post I submitted that the first step to simplifying the interaction was to elicit a specific prediction.
The measurable prediction from that example ended up being: “If the shoulder is damaged, there will be pain and weakness that won’t improve above 90 degrees of shoulder flexion.” Performing the first step well and getting good measureable predictions makes the next step so much more simple.
The next step is to set up an experiment that attempts to refute this prediction.
This step even has a name: behavioral experiments. I have long been enamored with behavioral experiments because it seemed consistent with what we do in therapy. But, as I mentioned in the first post, adding the concept of Expectancy Violation significantly improved the clarity with which we can engage targets of interventions. It is, in my view, a significant step ahead of targeting beliefs.
I have also long argued that our role as therapists is not that of one who makes the change for the patient. We don’t take pain away or heal pain. Instead, we set up the scenario in which the patient comes to their own conclusions and makes their own changes. We are context architects. We don’t perform the experiment. We set up the lab for the patient to run their own experiments. We are Alfred, not Batman.
So, at this stage the name of the game is to set up experiments for the patient to run. Here’s the thing. We WANT and are TRYING FOR a refutation of the prediction. So, we set up the experiment with this in mind and with skill.
Can they show themselves several position in which the shoulder is strong and therefore opposes the narrative of the weak and damaged/fragile shoulder? Can they show the capacity to improve their strength in the position of concern, more specifically refuting the prediction?
Can we disconfirm with a different way of doing the same thing, a novel movement?
Can they get the shoulder above 90 degrees using a different approach? Maybe they can get there if the hand is planted and stationary and the body moves away from the hand (closed chain shoulder flexion). Perhaps they can simply get their arm above 90 passively, refuting the specifics of the prediction of the shoulder being above 90 in any form (and gets us to a now more specific prediction about the way in which the shoulder must get to 90)
Can we use various physiologic mechanisms like conditioned pain modulation and exercise induced hypoalgesia?
If they perform a series of isometrics in a comfortable position (or even hunting for pain, as Erik Meira puts it), does the manner in which they can subsequently raise their arm change? Can we use desensitization?
If they repeatedly move up to and away from the position at which the protective behavior first becomes noticeable, does the behavior change? Do they gain motion or otherwise improve?
These are but a few of the many possible experimental methods in our laboratory arsenal by which the individual may test their predictions.
Some things that are important to include in this step.
Again the prediction needs to be specific about the outcome of the experiment. Just like in published research we don’t want any post hoc data mining to be able to squirrel around a negative finding that makes it seem positive. We need a clear demarcation of what meets and what refutes the prediction.
It may be helpful to track confidence in the prediction. “How sure are you that this bad outcome will occur if we do this?” They can rank this on a scale of 0-10. Then repeat the question after the experiment. This may help you gauge the success of the refutation. If the experiment was clearly negative (it didn’t bring about the bad outcome) but doesn’t change the confidence rating of the original prediction then something is askew and you may need to alter the manner in which the experiment is taking place or, more likely, the specifics of the prediction. Also, this re-assessment gives the individual a chance to verbalize explicitly and therefore acknowledge a change in their narrative.
Try to come up with or build toward experiments that can be repeated and run by the individual on their own. More on this in the next post.
Remember that the individual will update the prediction after the experiment is complete and so eliciting the prediction step is repeated. The shift in the prediction may be subtle or it may be large. Either way, confidence in the result will need to be built. That’s the next post.
This is the first in a series of posts where I hope to lay out a few concepts to simplify and guide the therapeutic interaction.
I’m going to start off with one of those “no shit, Sherlock” type of statements, but stay with me. After we have ruled out any reasons of need for immediate referral or indications that our care would not be appropriate, we next start looking for opportunities to make a positive change. To make this work we need to know what change will be meaningful and relevant to the person who’s seeking our help. We are not looking for any change that can be made. We are looking for a change that will make a meaningful impact to their particular issue (No shit, Sherlock!).
But, how do we decide what is a meaningful change? We can decide for the person and this might be reasonable. After all, we’ve gone through all this fancy and expensive education to gain access to all of this useful knowledge about problems and solutions. Shouldn’t we just tell the patient what they need?
Oh, if only it were that easy! This is what many try to do and leads to hearing or thinking the all too common saying of “you can lead a horse to water but you can’t make him drink.” If only the patient would do what we tell them they would get better! It’s so frustrating!! Of course some people will do what you tell them get better. But those aren’t the patients that cause us to lose sleep or spend our valuable personal time wondering why we couldn’t get our message across.
Here’s the insight: It’s better if the change is their idea.
This is not to say some bullshit like “the customer is always right” or “just give them what they want.” NO! The point is for us to use our skills of interaction to assist the patient in coming to an idea that will be helpful to them. This sounds so simple, but of course it is very, very hard. It will take a couple of steps to get there and we are going to work through some approaches that I think will help. And here’s the first step:
1) Elicit a specific and measurable prediction about the problem from the patient.
Our first therapeutic task is going to be to assist the patient to describe their issue at the level of an outcome that they fear or worry about, to a degree specific enough that it can be checked or measured. We want to help them formulate their issue in the form of a prediction. We don’t want to dictate their problem to them.
Why is this important? In my last post
I talked about some of the problems with trying to disconfirm a maladaptive belief. Beliefs are slippery. They are very difficult to pin down and therefore very difficult to change and are very prone to bias. We have confirmation bias
working against us here and if we try to change a belief by just presenting contrary evidence we might even make things worse through the backfire effect
! This is why we need them to come up with the prediction (instead of it being dictated to them) and it needs to be specific enough that it can be shown to be wrong (much more on this in the next installment). This is consistent with the concepts and processes of expectancy violation.
Our assistance will likely be needed and here is where some motivational interviewing skills come in very handy. In motivational interviewing the questions asked are open ended, allowing the patient to describe the issue in their terms. Reflective statements are used to draw out more detail in a non-threatening manner AND to reframe statements into something that may be useable in terms of a prediction and/or more adaptive.
There are many ways that we may accomplish getting to specific predictions. It could be as simple as asking “Can you show me how high you feel that you can safely lift your arm?” You can take your trusty goniometer off your Batman utility belt and get a measurement that gives you a specific (even if non-verbal) prediction of “I am not safe to flex my shoulder past 95 degrees.” You might want to get into some specifics about what they fear will happen if they move higher than this and how they knew that this was all the higher they could safety go. But either way, you’ve now got a measureable prediction to refute.
A more complex interaction could be as detailed as the following:
What is the outcome that you fear? (open ended question)
I won’t be able to go back to work as a drywaller.
What will bring about this outcome (unable to work)? (open ended question)
Not being able to lift my hand over my head or having to get a shoulder surgery.
How far can you lift the arm safely?
Demonstrates raising the arm to 90 degrees of shoulder flexion.
If you lift your arm past that point bad things happen (Reflective statement).
Yes, it hurts. It’s weak.
And that’s got you worried about needing a shoulder surgery or something that will keep you from being able to lift the hand long term (Reflective statement).
Yes, I’ve read that this type of pain and weakness may mean that there’s a rotator cuff tear or something. If that’s the case, if it’s damaged, then it’s not going to get better without getting it fixed.
I see. So you’re worried that something is wrong that won’t improve without surgery and the things about the shoulder that make you think that this may be the case is the pain and weakness when raising the arm past this point (mimics 90 degrees). (Summarizing statement)
This creates a detailed picture of the expectation and it gives us very measurable prediction!
From the patient’s perspective, If the shoulder is damaged, there will be pain and weakness that won’t improve above 90 degrees of shoulder flexion.
These are the problems from the patient’s perspective. But, you can also see how important the back and forth of the interaction was in getting to the point of some specifics. Now we are left with a specific prediction in the terms of why it is important to the patient (continuing to work).
We are now set up nicely to move to our next step, which will be to attempt to refute or falsify this prediction through experimentation. This will be the focus of the next post.
I’ve finally been lulled from my blogging hibernation! I first started sniffing the air when a discussion broke out between two of my favorite PT thinkers, Adam Meakins and Greg Lehman, regarding symptom modification.
Adam wrote this post, to which Greg provided a rebuttal and Adam a response. Both Greg and Adam agree that symptom modification is not necessary for recovery, but may be sufficient to guide practice. Greg and Adam demonstrate what a fierce debate can accomplish when the parties involved don’t get their noses bent out of shape over disagreements and at the conclusion of their discussion there appears to be agreement that symptom modification is 1) not necessary and therefore doesn’t dictate practice but 2) MAY provide a guide for practice. This goes to the point that I like to make that we often confuse opportunities for change with specific dysfunctions needing correcting.
The next question that I think is relevant is this: Under what (if any) conditions is symptom modification defensible?
Under what (if any) conditions is symptom modification defensible?
To answer this, let’s first look at the concept of belief disconfirmation.
Several of the speakers at this year’s San Diego Pain Summit spoke of disconfirming beliefs and even behavioral experiments got some air time , which made me very happy as these are two of my favorite topics! The idea behind belief disconfirmation is that the patient has a belief about the nature of the problem, and that belief stands in the way of recovery. It could be something like “hurt equals harm.” A belief disconfirmation is when this “maladaptive” belief is refuted in some manner, such as through education (cognitive approaches that aim to update the information that the beliefs are based on) and/or experiences (behavioral approaches that aim to demonstrate that the belief was incorrect). A modification of symptoms MAY be able to serve in this role of belief disconfirmation, which is potentially great! But, it is also obvious that there are scenarios where a modification of symptoms may only serve to strengthen the maladaptive belief! “I wasn’t safe to move until the pain was better. So, pain does equal damage!” or “When the therapist popped my back I felt better. A bone must have been out of place after all!” So, I don’t know that beliefs are always a good target to aim for. Beliefs tend to be tough to pin down. We (all humans) tend to actively seek out information that confirms our existing beliefs and ignore evidence to the contrary (confirmation bias
) or we alter the incoming information to match our beliefs. So, beliefs tend to be pliable, slippery, and bias filled and often make life a living hell for a anyone trying to change them. Don’t get me wrong. I think when belief disconfirmation can be achieved it is of huge benefit. I’m saying that it is a difficult target because of our human tendencies toward bias. In fact, what often happens when we are shown evidence that contradicts our beliefs is that we actually entrench even further in the belief! This is known as the backfire effect
. If you need to see this for yourself, just open up your preferred facebooking machine and go try to change someone’s political beliefs. Good luck!
So, what can we do? Enter expectancy violation. Sandy Hilton and I have gone on
about this in the past year on our podcast. This is the piece of the puzzle that really ties things together and gives us a path around this moving target of belief. It is very similar to the concept of belief disconfirmation with an important distinction: prediction. It pins down belief to something specific, making it less pliable and slippery to escape the disconfirmation. For example, the belief “hurt equals harm” may lead to the expectation of “I can’t bend forward without damaging my back.” Now, this is different. This gives us a specific action “bending forward” with a specific prediction, “back damage.” And if we prompt them to more specifically predict what “damage” would look like, we might get to something like “more pain, less mobility, less strength, etc.” Now in this scenario it becomes clear that a symptom modification may become very important IF it refutes the prediction. In other words, if they can be shown that they CAN bend forward, and were able to do so without the specific outcomes that THEY predicted, then they’ve refuted their own prediction. The specificity of the prediction reduces its vulnerability to bias, its slipperiness. When both the prediction AND the refutation come from the patient, so they own it, it should make the backfire effect less likely. Now they are not looking for confirmation. They are looking for an explanation.
So, getting back our question: Under what conditions (if any) is symptom modification defensible? In my view, symptom modification is defensible based upon 2 conditions: 1) it serves to refute a specific and relevant expectation and 2) the patient assigns the source of the refutation to themselves.
Symptom modification for its own sake doesn’t likely move the needle much, if at all, and as was described above could actually strengthen a maladaptive belief. Symptom modification to the degree that it demonstrates an ability of the condition to change may have some value but this too may be limited as the change is usually fleeting and may establish the treatment as a safety signal, where the patient attributes the change to something external to themselves, and/or foster some level of dependency. However, if the symptom modification refutes a specific prediction, then it can be very useful in my view. To be defensible, it also needs to support or build self efficacy, and be focused on a relevant and valued goal of the patient. I have many more thoughts on how this shift in thinking simplifies how we approach building the therapeutic interaction and I will spell some of these thoughts out in the next few posts.
I often describe that dealing with painful movement is a lot like getting out of a dark room. There are some approaches that aren't so smart. For one, standing up and running with the hope that you end up outside of the room is probably just going to end up with you hitting a wall. On the other hand, you can't just sit in the middle of the room without moving. If you want to get out of the dark room you'll have to explore. You would get up and carefully feel for a wall and then gradually feel around until you came to something familiar like a light switch or a door.
This is like painful movement. If you just ignore the pain and go hard, you'll probably hit the wall. At the same time, if you avoid movement altogether, well then you aren't going to get anywhere. You have to thoughtfully explore the edges of your available movements, looking for opportunities for expansion.
For some people, however, the doors are stuck and may even be locked. This is like chronic pain where an exit door has proven elusive. It doesn't mean it's not there, but it's not likely to be found or opened quickly. In these cases it is a good idea to learn to function better in the dark since the alternative is to not function. So practice getting around in the dark room and learn where the coffee table is hidden so you don't keep running into it. Keep exploring too, but gain some skills in the dark because you might be there for a while.
If you live in a house where the lights have a tendency to go out somewhat frequently (recurrent episodes of pain), getting really good at exploring would be a good idea. If you've gotten good at exploring, you'll get better and better at finding the door or the light switch over time. At least you'll gain confidence that it's there.
Both exploring in the dark and learning to function in the dark have their place. Just don't confuse one for the other because they have different purposes.