Saturday, February 18, 2012

New treatment encounter IV

New treatment encounter Part I
New treatment encounter Part II
New treatment encounter Part III
New treatment encounter Part V
New treatment encounter Part VI

The sturdy treatment relationship you make with a new patient should be like a new well-caulked boat to help them across their river of feeling Doomed by Diagnosis. You are the distraction while they supply their own motivation, usually enough to get themselves out of pain.

There are some rivers, sometimes, that just can't be crossed, however.

There will be some people, rare fortunately, who just can't seem to muster up the inside strength to even get into the "boat", even with you helping them, and explaining how ferrying works.

Don't ever take people like this personally, or get mad at them, or blame them for not getting you. It's not their fault they don't get you. It's not about you! It might be something to do with how their brain:

  1. Was wired up at birth, or
  2. Became wired up after, through life. 

Each person who walks in your door is an unknown quantity. You have no idea what they've been through or what they're like until you interact with them a bit. Even then, you'll only ever know a vanishingly small amount about them, only what they let you know. When you interact directly with their nervous system you'll get more of a clue, but even then, if they can't light up their own kindling inside themselves, nothing you do TO them will make a pick of difference, probably.

So we could call this post in the series, troubleshooting.

When somebody has yellow flags sticking out all over, a very useful picture to show them, and discussion to have with them, is the "neuromatrix model of pain" discussion.  I keep one of these diagrams around just in case - mostly I keep my pain education superficial and peripheral, because that suffices for most of the people I see. But once in awhile, my oh my, I see someone who really needs to know about the neuromatrix model of pain. See this post from a few years back, about a patient I saw that I called "Rosie".

To use it effectively, first of all, ponder it yourself, deeply, until you understand it thoroughly. Tape the diagram to the fridge, to the wall beside your computer, keep one near the toilet, one beside where you relax in the evening, one near your bed in case you wake up and need to look at something for awhile before you can go back to sleep. This effort will pay off, big time, in terms of your self-respect as a human primate social groomer, if ever you have a yellow flag person walk in and your ordinary approach is futile. With a diagram of neuromatrix model of pain, you can sit down with your patient and explain, without ever blaming them, how pain is made by the brain as an output by the brain's own machinations. Brains are like churns - they take inputs (everything on the left side of the diagram, including all your own efforts as therapist) and churn it around, and produce outputs, one of which is "pain" perception. Pain perception is NOT the patient's fault. It's coming from parts of the brain that are old, more primitive threat detector zones. It's a normal process, and usually people can turn that off one way or another, even if they require a bit of help in the process, which is why we human primate social groomers are around in all our vast numbers. We let people use us so they can get themselves better.

The best description I ever have seen and read to date of the part of the brain that handles nociception is in Mayo Clinic Medical Neurosciences 5th Edition. The authors call it the "internal regulation system".  Here is a little picture of a slide I made of it. It regulates stress, emotion, threat, is covered in opioid receptors throughout, operates quite autonomously, is ubiquitous in vertebrates, runs everything physiological, and (this is the interesting part) can be heavily influenced, trained even, by more "rostral centers".

"Rostral centers" is code for "frontal lobes", the thinking, socially conscious, cognitive-evaluative parts of the brain: Here is a very nice, short little video of how the brain processes social stimuli.

Social cues in the brain (Scientific American)
 Social cues in the brain (Scientific American)

It's very, very easy for people (i.e., human primates with a great big focus on watching/interacting with the rest of the "troop") to be so caught up in their own psycho-social brain activity that they have no clue, really,  how to attend to their own bio-psycho aspects. And pain is biopsychosocial, not nociception, not only "bio", not only "psycho". I happen to think that it arises when functional, firing, awareness-driven relationships between different systems inside the brain are a bit out of whack with each other, for example if the "person" in the brain has no awareness of physical discomfort until all of a sudden, it's too late, and they're stuck in a bunch of bad movement habits, or more specifically, a bunch of bad lack-of-movement habits! Just a hunch. However, conscious awareness is the only lever in there for PTs to pull, really. Never underestimate the ability of a good therapeutic relationship, one that can capture attention appropriately, using those already well-worn, socially attenuated processes in a patient's brain, to help them get off the square they are stuck on, pain-wise. Usually. Or at least move on in life with less dis-empowerment. Above all else, avoid disempowering patients. It's very noceboic. Negative expectations are associated with cholecystokinin being released in the brain stem, with the overall effect of enhancing ascending nociception. Which brings us back to the descending modulation system.

Anyway, this internal regulation system/descending modulation system is in the core of the brain. It's already working at birth, keeps us alive, regulates our heart, lungs, hunger, all drives, all resolutions, dampens all our nociception for us. Usually!

If (for whatever reason...) the frontal lobes, in particular the prefrontal cortex, which doesn't fully myelinate until into our third decade (!) ... if for some reason, it doesn't hook up properly to this internal regulation system, our patient may not have the means by which their brain can learn to conquer pain from inside itself. If that's the case (and remember, we have no way of knowing - it's all a guess) ... if that's the case, then all your fancy-schmancy multiple kinds of therapies are completely useless, and the treatment container boat you built will sink, unless you keep on trying to teach this patient what they need to do, and hope they can figure out how they can manage to do it.

The other possibility is that they may have some sort of bio issue, maybe a receptor problem or a protein problem or something their nervous system needs but can't make or a system that makes way too much Substance P in the cord or wildly enthusiastic microglia in their spinal cord or something. There are so many ways things can go wrong biologically and developmentally that it's amazing that usually everything turns out so well. 

Anyway, don't ever lie to them. They will have been through many practitioners and will have been disappointed by all of them. So the last thing they need is heroics. Do not become another person in their biopsychosocial existence who has promised them some kind of operator model magic in the form of a gizmo or a tool or a magic technique, and then not delivered. If you've explained the nervous system to them, then it should have been clear to them all along that only they have control of the magic wand, not you.

They need solid information! It won't matter if they don't suck all of it up instantly - you will at least have held up your end of the therapeutic relationship as best you could, by giving them excellent food for thought. All you can do is provide it and hope their brains will work toward being able to use it some day.

Nocebo Effects, Patient-Clinician Communication, and Therapeutic Outcomes 

1 comment:

Diane Jacobs said...

A Facebook friend contacted me there, to say

"Thanks for this series of posts Diane - I really, really hope they're going to turn into a book. Or part of a structured course. Your exposition is so clear, thoughtful, and valuable! I wish I'd had this to read when I was just starting out..."

Apparently she had trouble posting her message here directly. Something about the CAPTCHA not working for her. Anyway, I'm posting it for her.