Beating around the bush

From the Australian edition of The Conversation

A ‘no-consequences’ education produces unemployable graduates’

A research centre in the UK recently found that lavishing praise on students, particularly low-attaining students, may be counter-productive. By providing a no-fail, no-consequences environment in which the top priority is to make everybody feel good about themselves, we are doing little more than setting young people up to fail(emphasis added)

Chasing down the links for the article leads here and provides some teaching “dos” and “don’ts”, including

Six teaching dos:

– Have deep subject knowledge.

– Ensure quality of instruction, such as good use of questioning.

Teaching don’ts:

– Use praise lavishly.

This all reminded me of a nice little article that was also published as a blog post by Lorimer Moseley;

“A frank approach to interpersonal communication brings with it some challenges, but having to dig oneself out of a hole, created by strategically avoiding the truth, is not one of them…

We tend to endorse the complexity of the brain and its fundamental role in what we experience. Unless, of course, we are talking about pain…

This is problematic, not least because those in chronic pain first had acute pain, and to change our story once they are chronic might give the distinct impression that we are clutching at straws. Indeed, by the time people progress from acute to chronic pain, our previous avoidance of the truth – our unfortunate trivialization – has dug a very big hole from which it is difficult to climb out.”

Teaching people about pain can be confronting – for both the ‘teacher’ and the ‘student’. Euthanising biomedical /biomechanical sacred cows, such as “my back is out of alignment because one leg is longer than the other and that’s what’s been causing my pain for the last 10 years”, or “It’s a slipped disc” can lead to conflict and discomfort for all parties. But it needs to be done – respectfully, carefully, and never denying the lived experience of the patient, but it needs to be done.

Early on in my attempts to Explain Pain, I was guilty of beating around the bush- not wanting to make people feel bad or create conflict and confrontation, I’d let, what I thought, were little things slip – but I was just digging a hole for myself, and looking back, there were many pits I failed to climb out of, with the consequence being the intervention failed – horribly at times.

Helping people to achieve conceptual change often necessarily requires the creation of “cognitive conflict” (Kang et al 2004), which involves identifying pre-exisitng ideas and presenting evidence that is in direct conflict with them. For example, contrasting the pre-exisitng notion that pain is ‘created’ in the tissues, detected by ‘pain sensors’, sent along ‘pain nerves’ and then registered in the brain, with the idea that, pain is an emergent construction of a human being in response to perceived threat affected by multiple interacting factors across biological, psychological and social domains, is one of the key cognitive conflicts that Explaining Pain aims to create. When a new, scientifically accurate (as best you are able at the time) but conflicting concept is presented respectfully and in an interesting way (Moseley 2003), the new concept is more likely to be adopted and used in the future (Kang et al 2004).

Creating cognitive conflict is not telling someone that they are wrong or arguing with them, it’s about presenting understandable information that will contrast with the existing beliefs – it’s about not beating around the bush.

A simple cognitive conflict approach may sound something like “Most people think “x”, we understand why people think “x”, and its even quite intuitive to think “x”, but, to the best of our current scientific knowledge, we know that it is more accurate to think “y” (where “x” and “y” are contrasting concepts). This can be done verbally, or in written form where it is called a refutation textExplain Pain has many examples of this when you read it with this theory in mind.

But it requires some artfulness, a deep knowledge base and skillful communication – a patient may well begin to take on a new conceptualisation of pain, but this can lead to further conflict- such as the one that arises when they consider the thousands of dollars spent (wasted?) on therapies to “realign their spine” and “put the disc back in”…

Of course, there are other issues when presenting new, more accurate and conflicting concepts – the person ‘teaching’ and the person ‘learning’ both need to have the appropriate “schemas” or mental frameworks to take the new concept on – they may particularly need an emergent way of thinking to really understand pain – but that’s another topic altogether.

Feel free to share your tales of hole digging woe, but also odes to breaking free of beating around bushes, in the comments below. But not before enjoying a musical interlude from some very frank communicators – Acca Dacca with “Beating Around the Bush”

-Tim Cocks

www.noigroup.com

Kang, S, Scharmann, LC & Noh, T 2004, ‘Reexamining the role of cognitive conflict in science concept learning’, Research in Science Education, vol. 34, no. 1, pp. 71-96.

Moseley, GL 2003, ‘A pain neuromatrix approach to patients with chronic pain’, Manual Therapy, vol. 8, no. 3, pp. 130-140.

12 Responses to “Beating around the bush”

  1. davidbutler0noi

    Thanks Tim – beaut post.

    The essential element of conceptual change is that it requires conflict. Not all education requires conflict of course; in some situations, gap filling knowledge enrichment suffices. And with the use of some clinical rhetorical skills, conflicting knowledge can usually be delivered without warfare.

    I think too many rehabilitation practices exists with a softly softy, keep everyone happy approach. Patients and professions are the ultimate losers.

    David

    Reply
    • timcocks0noi

      Thanks Dave
      I know I’ve been guilty of this in the past – its what made me think about writing this post. Trying to be ‘kind’ or ‘nice’ or ‘liked’ as a therapist and not confronting an individual’s misconceptions is none of these things, I’ve learnt. For me, part of maturing as a therapist was learning to respect all patients enough to challenge their misconceptions and create some cognitive conflict. Doing this well – that took a long time.
      Cheers
      Tim

      Reply
      • aidantighe

        Thanks Tim,

        Great post, I also love David’s comment that often conceptual change requires conflict. I defiantly reckon that early in my career I would beat about the bush and take the softly softly approach with my patients. There was a time when I dreaded patients whose opening line was along the lines of “well I’ve got 2 bulging discs” now I relish hearing that statement as I feel well equipped to help the patient hold a mirror up to their beliefs and help them to see the potential contradictions in their belief system.

        Recently I had a patient with a long history chronic pain, a history of failed treatments including multiple spinal surgeries, at the time he was contemplating a second spinal fusion surgery in few months. About three sessions into our treatment I felt we were going along fine and he was “getting it”, but he comes into the clinic and says “I’ve been thinking about what our plan is here and to honest I think you’re flat out wrong, this doesn’t make sense to me and it can’t be the way to go”. Obviously things were not going as well as I had naively presumed. Not to worry, we sat down and trashed the whole thing out, we got rightly stuck into it and eventually in the end we got there together. It was a bit ropey for a while but we made it. A couple of months later he was flying it, surgery was cancelled, and he was well on his way to recovery. I asked him what the key was for him in turning things around. You know what he said? “that day we had the argument, that was the day the penny dropped, I left that day and thought we might be onto something here”. The conflict was the key!!

        To illustrate just why conflict is so important I’d like to quote a section from the excellent “Aches and Pains” book by Louis Gifford, (which by the is a must read for all who deal with people in pain) as I believe he sums it up quiet nicely;

        Humans tend to only gather the information and facts that fit with their personal set of hypothesis, theories and beliefs and at the same time they tend to dismiss or ignore anything that doesn’t fit. We’re very good at finding “facts” that confirm our beliefs and very bad at finding evidence that might disconfirm them. Sutherland goes on…” To establish a rule is likely to be true one must first try to prove it false, but this is just what people don’t do.”

        I think the above illustrates how humans think, both patients and clinicians, and how important critical thinking and some conflict can be in helping us all change our views. To be honest, now I embrace the negative beliefs, and relish getting stuck into them for then real change can occur. Obviously we still have to tailor our style and approach to the individual, some people need loads of empathy and compassion to help build themselves up again, but others need a more direct approach, its important to know which is which and adapt as we see it. To be honest the tough ones for me now are the ambivalent ones, the ones that don’t offer any strong opinion on their pain either way, you end up with less conflict but also less engagement and ultimately much less change. So let’s embrace the conflict it can really help a lot.

        Now to find a way to shake up the ambivalent …

        Thanks for sharing all ye’re knowledge,
        All the best,
        Aidan
        @AidanTighe

        Reply
  2. Efwef Gwerb

    I agree this is very pertinent.

    The problem is that the illusion is comfortable and the reality is stark. Therefore it takes courage to open up to it.

    I can work in the 1980’s Physio style, be very comfortable and successful and get good results using manipulations and dry needling and all that crap. What motivation is there for me to scratch below the surface appearance and see what’s really going on? I have the perfect defense: I can “fix”my client’s sore back. Well, I can fix it most of the time…

    Consider life in general, beyond physio. The actual realities of life are stark, very stark. Everyone dies – there’s your first reality! Then there’s torture, starvation, corruption, war, … you get the picture. Too depressing? Yes, of course! Now, how to handle that? One popular method is to deny to conscious awareness anything which is deemed ‘unacceptable’. I know physios who do this – everything is ‘bright and shiny’ all the time. Such an approach certainly has its merits. But what happens when you get a client who is fat, ugly and in chronic pain? Is that picture acceptable or do you reject the person entirely? Maybe you’d prefer fit, attractive clients with minor issues?

    Don’t get me wrong here, I’m not suggesting that focusing on the negatives is the solution; that’s probably the worst thing one can do. The mind needs a way to integrate ALL of reality, not just that which is pleasing to the 6 senses. That’s the true test of a therapist – someone who can do that. And it’s the ONLY thing worth working for.

    EG.

    Reply
    • timcocks0noi

      Thanks EG
      Nicely put
      One of the key ideas of noi is the freedom of expression of all human ‘outputs’, as opposed to paradigms of control. Integrating all of reality- coping with it, dealing with it, understanding it and learning from it is all a part of life.
      Cheers
      Tim

      Reply
  3. Efwef Gwerb

    Hi again,

    Please have a look at this: http://en.wikipedia.org/wiki/Positive_illusions

    As mentioned yesterday, a rigidly positive attitude could mean that the holder of such an attitude is out of touch with reality. Despite evidence that the effect of most physical therapies lasts only ~30 minutes due to pain gating, many practitioners ferociously defend the efficacy of their treatments, unwilling to admit the possibility that professional relationship factors are the key in determining outcomes.

    On the other hand, positive illusions have been shown to be very good for mental health. And a happy confident practitioner is crucial to successful client outcomes as we know from the placebo studies! Dilemma!

    The thing is, once you take the Red Pill, you can’t un-take it. The Red Pill does have side effects, such as total and utter disillusionment with an entire professions (includes surgery and medicine). But the process of upgrading one’s understanding can be made more palatable with demonstrations of improved effectiveness and precision. This is why I love seeing video demonstrations of healing people using confidence, rapport and suggestion alone. It is so much more direct, precise and modern.

    In a way it’s like updating to Windows 8. At first it sucks because everything is new and hard to navigate. Then you gradually see it’s faster, more secure and more… real! When Windows 10 gets released, you just have to be prepared for more upheaval. Physio upgrades won’t end with the Neuromatrix… at least I hope they don’t.

    Now to change pace slightly. I had lunch today with a non-physio friend. I mentioned what I posted on NOIJAM and asked whether she thought I was being too harsh. She’s got a good brain and sometimes I like to ask her feedback on such matters. She said words to the effect of “Yes, that sounds like it could be quite correct. But you know what you’re doing, don’t you?”

    “What?” I asked.

    “You’re trying to get everyone to think like you do”.

    Ouch. Reality colliding with my ego! Now I have to consider my posting activity online, because what she said was undeniably correct.

    EG.

    Reply
  4. bigd7876

    I think that my main challenge in presenting some of this information is the beliefs of physicians (our clinic’s main referral source). I have many physicians that have deeply ingrained beliefs about pinched nerves, slipped discs, spinal fusion, etc. that it is often a major fear of mine that if I contradict what the patient has heard before, I may lose a referral source. I have also recently had an experience with a physician in which I referred a patient to them for further testing of a condition unrelated to their back pain, and this physician instructed the patient that their back pain would not respond well to physical activity, and that she should immediately discontinue therapy and go home and get in bed. I did not know how to deal with this situation, as when I spoke with the physician, he was adamant that I could only cause more harm because her pain indicated there was severe damage to her spine! I beat around the bush with him because I am afraid of losing the referral source.

    Do you have any suggestions for how to best deal with this?

    Reply
  5. davidbutler0noi

    I have been pondering this post for a bit – thanks for putting it up.

    There is obviously no easy answer. This situation depends on where you are too. The once common dinosaurial hierarchical situations, often using faulty evidence are breaking down in many parts of the world so my initial advice is to “hang in there”. I am also aware of professional challenges relating the fact that what you can do as a therapist may be more powerful in some clinical states than what a physician can do with pharmacology. Unfortunately this does not creates universal acclaim.

    Other options we have used over the years include carefully sending evidence and also having informal meetings with other health professionals – a few drinks and nibbles after work with a short presentation along the lines of what we can do to keep your patients happy, well and better. I also think that if someone comes with a diagnosis of say “pinched nerve” you can “keep” the diagnosis but slowly reframe it so you don’t have to offend the labeller too much.

    And finally, truth and quality win out in the end. The patient comes first.

    Best wishes

    David

    Reply
  6. bigd7876

    Thank you for the advice. I have been hopeful as some of the physicians we work with are increasingly relying on our expertise and experience. I guess persistence is the best policy, trying not to offend while still putting forward the best pain education possible, and wait until the dinosaurs go extinct. :)

    Reply
  7. Nigel Roff (@WillsmereHealth)

    I have been pondering this one for a while. Firstly I’ve dug plenty of my own holes over the years trying to be “helpful”. These days it’s just the odd divot here and there and I replace the divot as soon as I can. I think there is such a long way to go though. Keeping things a simple as I can. There is still a balance of power issue. Being an Osteopath I am not very high up the health professionals food chain. Simply put my word is still not as strong as their GP, even if I present current evidence. The other main issue I wrestle with is the “shades of gray” (as I call it) with pain science. Talking about arthritis, we love to say,”it’s normal”,”studies show no correlation between arthritis and pain” etc, then the patient says,then why do they do hip replacements? We can either say, well, that’s extreme and creating constant nociceptive input etc. Then the patient reasons and says, well how do you know my arthritis on this scan isn’t enough to cause my pain? , then you have to be wary not to get the shovel out and start digging. Explain pain is a great step forward, the hard thing is “what are we going to do about it?”. That’s the bit patients care about.

    Reply
  8. aidantighe

    Thanks Tim,

    Great post, I also love David’s comment that often conceptual change requires conflict. I defiantly reckon that early in my career I would beat about the bush and take the softly softly approach with my patients. There was a time when I dreaded patients whose opening line was along the lines of “well I’ve got 2 bulging discs” now I relish hearing that statement as I feel well equipped to help the patient hold a mirror up to their beliefs and help them to see the potential contradictions in their belief system.

    Recently I had a patient with a long history chronic pain, a history of failed treatments including multiple spinal surgeries, at the time he was contemplating a second spinal fusion surgery in few months. About three sessions into our treatment I felt we were going along fine and he was “getting it”, but he comes into the clinic and says “I’ve been thinking about what our plan is here and to honest I think you’re flat out wrong, this doesn’t make sense to me and it can’t be the way to go”. Obviously things were not going as well as I had naively presumed. Not to worry, we sat down and trashed the whole thing out, we got rightly stuck into it and eventually in the end we got there together. It was a bit ropey for a while but we made it. A couple of months later he was flying it, surgery was cancelled, and he was well on his way to recovery. I asked him what the key was for him in turning things around. You know what he said? “that day we had the argument, that was the day the penny dropped, I left that day and thought we might be onto something here”. The conflict was the key!!

    To illustrate just why conflict is so important I’d like to quote a section from the excellent “Aches and Pains” book by Louis Gifford, (which by the is a must read for all who deal with people in pain) as I believe he sums it up quiet nicely;

    Humans tend to only gather the information and facts that fit with their personal set of hypothesis, theories and beliefs and at the same time they tend to dismiss or ignore anything that doesn’t fit. We’re very good at finding “facts” that confirm our beliefs and very bad at finding evidence that might disconfirm them. Sutherland goes on…” To establish a rule is likely to be true one must first try to prove it false, but this is just what people don’t do.”

    I think the above illustrates how humans think, both patients and clinicians, and how important critical thinking and some conflict can be in helping us all change our views. To be honest, now I embrace the negative beliefs, and relish getting stuck into them for then real change can occur. Obviously we still have to tailor our style and approach to the individual, some people need loads of empathy and compassion to help build themselves up again, but others need a more direct approach, its important to know which is which and adapt as we see it. To be honest the tough ones for me now are the ambivalent ones, the ones that don’t offer any strong opinion on their pain either way, you end up with less conflict but also less engagement and ultimately much less change. So let’s embrace the conflict it can really help a lot.

    Now to find a way to shake up the ambivalent …

    Thanks for sharing all ye’re knowledge,
    All the best,
    Aidan
    @AidanTighe

    Reply

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