Friday, February 17, 2012

New treatment encounter I

On SomaSimple, somebody asked about the best time to inject pain education into a treatment session, as if pain education were in a foreign language. I understand the problem. So let's look at pain ed. as being in an unfamiliar language. These days we have the option of continuing to speak the old (hopefully about to be obsolete) language while painfully trying to learn and translate in the new one, or we can plunge right in and use only the new one. I recommend switching completely to the new one. 

What languages am I talking about? 

Generally a patient speaks haltingly in Mesoderm-ese*. This is the language they will have recently assimilated from their doctor or from previous health care providers, or learned from the internet. All PTs were raised in this language. It used to be the only language around, but there was no clear word for "pain". Instead, there were only nouns for body structures and parts. And pain was assumed to be some kind of bottom-up thing. It's clunky language that doesn't fit modern times or new understandings. It's a bit like as if we went around saying "thee" and "thou" and "yea verily" in ordinary life. It sounds awfully dated. 

Now, we have Ectoderm-ese**! There are many ways to discuss "pain" in this new language. I'm going to write a series of posts to explain how and why I teach patients Ectoderm-ese. Several useful things are accomplished simultaneously, as we will see.  

There is a small window of opportunity available to teach your patients this new language. Very small, unfortunately. During the first session, people tell you about their pain, what they imagine it's from, all that. The window is: 

1. after they are done explaining as best they can, and..  
2. before you examine or treat them. 
This is your best chance, your one shot, your only hope, really, to get a foot inside the door, and expose them to Ectoderm-ese, in the context of explaining to them what you intend to do, what you're like, how you think, because this is when they will be the most receptive, right at this moment: to them, you are still an unknown quantity and they want to know more about what you think and what you do. They need to build up a picture of you they can carry away after. Know full well they have a filter up about whether they can trust you not to hurt them, so take full advantage of the opportunity to dispel their fear in advance of touching them. It's a precarious moment. Handle it well - explain to your new patient how you intend to handle them, well

I invite them to come over and take a look at the only poster I have up; it shows the nervous system all by itself. 
  • I point out the complete lack of meat, or bones or joints. 
  • I tell them this is the only part of the body that can produce "pain" for them. 
  • It's the nervous system, and "it comes all the way out to skin, which makes it easy to work on". (This is the first big hint I give them about how I work.)
I tell them a few choice details about it, just like I'm telling a story. I tell them...
  1. ... it's comprised of 72 km of nerves, a brain 5 times bigger than it needs to be to run a critter "our size". (I stay deliberately vague here - lots of people have 'size' issues no matter what size they happen to be, so I just ballpark all us humans into the same size category to help a therapeutic relationship establish itself.)
  2. ... even with all this length, even with the huge brain, it's tiny, only 2% of the whole body, but because it's busy 24/7, even when we're asleep, and because it runs all operations, it sucks up an amazing 20% (!) of all available oxygen and glucose, all the time, at speeds of about 270 miles per hour, so it's a big energy suck. 
  3. ..."you are part of it. It's not part of 'you', the way we usually think of our body parts. You are part of it. 'You' are the human bit in there, but most of it we have in common with all the other critters out there that have vertebrate nervous systems. It runs 'you'. It looks after 'you'. It keeps 'you' alive. It puts 'you' to sleep at night so it can do other things, but it keeps your heart beating and your lungs working, right? It's your survival machine and your threat detector. It wakes 'you' up in the morning because it needs you to get it something to eat. It never shuts off !"
  4. ... it's your operating system. It's an old evolved thing, and some parts are really old while other parts are quite new, and they're all hooked together, and sometimes it can get itself into a glitch. Usually that's all that's the matter. So, we do a systems check and help it fix itself. I'll explain how we can do that in just a moment, but first, I want to get back to the part about how it needs so much energy for its puny size. 
All of this is done in just a minute or two. Most peoples' attention spans are long enough to last through this little orientation. Especially when a lot of "you's" are thrown in, with references that track back to their ailment, how their brain might be perceiving it. You are laying, in plain sight, a trail of bright markers for them to follow. 

The main goal here is to recruit the patient to working with you, by introducing a new character into the drama - the nervous system. Put a mustache and black eye mask on it if you want. It can be our provisional villain, if you need one, or it can take on any role the patient needs it to take. You want the patient to realize that they and their own nervous system, although inseparable, are not exactly one and the same thing.  They quickly realize they can be agents, they can have a bit of leverage at their end - you have made it clear it's not their fault, this will be a team effort, that there is a possibility it will be "you and them" on one side, against their nervous system's undesirable behaviour on the other side. This prevents any potential "oppositional defiant disorder" from occurring on the part of the patient at the outset, and seals a treatment relationship into committed existence - the patient has been let in on the scoop, and realizes s/he has a job to do, a role to play. You will build more layers on top here eventually, but this moment is when and where and how a foundation crucial to the successful unfoldment of the therapeutic encounter can be laid. They start to understand that they are actually in charge, that you are there to help, not take over. They have locus of control, inside themselves - it's not beyond them, out in you or in the room - it's inside them. They don't quite have full access to it yet, but at least they now know that it's inside them somewhere. Their brain will go to work on that little bit of news as you move them onto the next piece of information. 

More to come.

*Mesoderm: (noun used in place of "embryonic mesodermal derivative") - Refers to the 98% of the body that is structural and non-signalling: bones, joints, muscles, tendon, ligament, fascia
**Ectoderm : (noun used in place of "embryonic ectodermal derivative") - Refers to that 2% of the body that is the nervous system and can mount an action potential: brain, spinal cord, nerves and receptors in the outer layer of skin

Pain. Is it all just in your mind? Professor Lorimer Moseley - University of South Australia
You tube video, about 49 minutes


Beth said...

Thanks. Just brilliant!

Beth said...

Thanks. Just brilliant.

A. Bjerre said...

This is SO good, Diane! Thank you.

Angie said...

Oh my goodness. Thank you. Building this stuff into my repertoire so that "I" sound like I know what I'm talking about has been such a challenge. I've just started reading "The Patient's Brain" Fabrizio Benedetti which I ordered after reading one of your posts and your new treatment encounters posts are helping my brain.