The Art of Patient Communication in Pain Management

The Modern Pain Podcast is a proud member of the PT Podcast Network. Make sure you check out pt podcast network.com for other awesome PT related podcasts. Welcome back to another episode of the modern pain podcast. This week, we have a conversation with Ben Whybrow physiotherapist, specializing in pain management at an NHS pain clinic. Ben's going to discuss the multidisciplinary approach to treating complex pain cases where they emphasize the importance of patient communication. And empathy. He shares his thoughts on managing difficult conversation around ingrained beliefs, the effectiveness of group dynamics and treatment and strategies for addressing emotional challenges we see daily in the clinic. This is something you cannot learn in the classroom and you have to learn it sitting in front of another person and having these difficult conversations. Thankfully this episode is going to help you better navigate these conversations in the future. Enjoy the episode.

This is the Modern Pain Podcast with Mark Kargela.

Welcome to the podcast, Ben.

Well, thank you for having me, Mark. It's a pleasure to be here.

This is another one of those like digital friendships, uh, from X, Twitter, whatever the heck we're calling it now. Um, where, you know, I always, as I'm having discussions on there, it's one, it's a good sounding board of ideas and thoughts and seeing what people are doing out there. And a lot of great researchers, obviously I always say it's like, you know, free continuing education because you're able to. You know, see what's getting published, see a lot of discussions around it, things that normally you'd have to wait to a conference to get in front of those folks. Um, if you're able to attend those, but, um, Ben, you've been involved in some great discussions and I've obviously enjoyed your perspective. We wouldn't have you on the podcast. No, I try to keep all perspectives in mind and, and try to engage with even ones I may not. Agree with but yours, of course, I do before we get into talking about what we'll talk about today and some of the stuff around difficult conversations I'd love if you could kind of introduce yourself for the audience and kind of let them know where you're at and what you're up To

Thank you. Uh, so yeah, my name is Ben Weibrow. I am a physio over in the UK. Uh, I work in a pain clinic for our wonderful NHS. I've been doing that now for four and a half years and I'll be next year, uh, 10 years in the profession. Uh, on top of that, Um, my other smaller job is I work for, uh, now the University of East Anglia, we do something called clinical communication skills, which is, uh, something they do in the medical schools around the country. And it's essentially, um, well, facilitating or teaching the medical students how to talk to patients about various things. And it starts fairly simple with things like taking a history, building rapport, and then as their years go on. It gets to more of the interesting things like, uh, sexual history, reproductive history taken, death and dying stuff, palliative care, breaking bad news, um, there's even a pediatrics one in the fourth year where they're getting kids from a local school. Um, so I do that a small amount, but my main job, uh, is with, uh, uh, yeah, NHS Pain Clinic, which has been, yeah, four and a half years now, and most of my career in the kind of musculoskeletal field. Thank you. Bye.

Now NHS pain clinics. What does that look like as far as what kind of setting is that and what what kind of? Obviously, we're working with patients who are dealing with often some complex pain issues, but I'd love if you can unpack a little bit of like what a day looks like in the clinic there. And I know sometimes there's some challenges. Uh, you know, we spoke to people more last week and he had mentioned for some of the pain programs. I don't know if that's currently with your pain programs. There could be a decent way to get in. I'm curious what the Yeah. What that environment's like over there,

So, I can only obviously speak for mine. Pain clinics or even pain services, if we call it that, are going to look different geographically across the country. But generally, you'll have, it's an MDT approach. So, physios, we have psychologists, our service has occupational therapists, and then we have nurses and consultants as well. We are seeing the people where They have been through the mill of conservative management or surgical management as well. They have had all of their standard investigations that they shouldn't be expecting any more scans, blood tests, anything like that. The diagnosis in theory should be done. And our patients can come from anywhere. So yes, there is a ton of back and, or back and leg pain, neck, or neck and arm pain, or widespread fibromyalgia, um, CRPS, things like that. But, we also get, like, for example, uh, post surgical pain after cancer surgery, um, hepatic neuralgias. In theory, it can be pain anywhere, um, that includes pelvic pain as well. Um, and we will... essentially work as the team to support the person. Um, the person, depending on their needs, may not have any physio input at all. They may have, uh, a lot of physio input and not much psychological input. Obviously, we're trying to treat them as people, not as pathologies. And we do, like Pete Moore had, we do have pain management programs. So a pain management program, do you have them in the States at all, Mark?

not as many as we should have, we used to have multidisciplinary pain programs, but then just the per usual in the U. S. The financial components of it. It's hard to deliver and keep it a financially viable thing in our, our more invasively profited system that we, that we currently reside in here in the U. S. But some, but not, not a ton.

So, we have a pain management program. It is a combination of the physio, psychology, OT and a few other bits. Um, now the time scale is variable on different services. Um, so ours, for example, it is 3 weeks, 4 days per week. And people either do it virtually over Zoom or they come in in person. I know there are other services that do theirs once a week for 12 weeks or twice a week for 8 weeks. It depends on the service and the needs of the people. Um, but it's the combination of the entire team, and I'm going to be honest with you, the patients on it take more from each other than they take from us, which is what we want ideally because they're meeting people like themselves who they probably haven't met in society before. You know, you and I see people with persistent pain every day, right, we're used to it. People in society. Or patients we see, they often may not, might not meet many people like themselves and that combination of when they, we start them on the first day and we say, you know, how does your pain affect you? And someone says, I struggle to sleep, I struggle to, you know, do my shoes, I was working, boom and bust, um, affects all aspects of my life, from financial to intimacy to all sorts of things. And you see them next to each other, nodding along going, yeah, it affects me too. It, it's that group dynamic that almost brings them together. Um, there were, like anything, there was a way I, the weights depend on where you are in the world. Um, But I would say it's, you know, we will always assess our patients first before they come on a program because you want to make sure someone's ready for it. What you don't want on a program is someone coming in, not knowing what their problem is or why they're there, or if there's any unmet, unmet needs. So for example, In our service, we do get people where there are more mental health needs than maybe other services. And sometimes they need to be addressed first before they can come on a program. Maybe they might not be good in groups of people. Maybe they might not be able to do the timescale. Um, So we will always do our best to make sure that the right person ends up in the program. And it's at the right time for them. Um, Because they're only going to do it once, um, generally. Although the new PMP guidelines in the country now say you can do it more than once. Um, but we want to make sure it's the right time for them, and obviously for everyone else that they're with, so everyone can get the most from it. Um, I will say for our service, we do follow them up at a month, six months, a year later. Other services follow them up, follow them up at different time lengths as well. Sometimes it's a few months, sometimes it's variable. Um, but... I would say for our service at least, a program in the long term is, if you look at all of our outcome measures for everything, it's the best thing we can offer them.

I think it's fascinating. The whole group kind of community components of that to let you, you alluded to where yeah, We have patients who, like you said, haven't really experienced anybody who's walked in their shoes. Um, you know, we've, they've often encountered healthcare people that, you know, if they're trying to validate, hopefully, which unfortunately doesn't always happen. Um, it's hard for them to truly validate because they haven't necessarily, they don't have that, you know, experience to share with somebody that, you know, another fellow person who's struggling with pain does. I'm wondering what your thoughts are of that whole group versus individual treatment dynamics. There are two different dynamics, obviously, and you said, like you mentioned, like the group dynamic has its strengths and the individual dynamic has its, it has its challenges and strengths as well. I'm just curious what you found as far as like the differences and, you know, how do you navigate maybe, you know, those, those challenges between those two different contexts.

I mean. Our program, what helps in a way is that it's generally the last thing they will do, just due to the nature of the time length waiting in the, sometimes in our service as we have consultants depending on the type of pain they have, they may have had some invasive treatments first to try and support them with managing the pain. Um, so usually we will see them individually beforehand and we can get a good grasp of meeting this person at the time. Is this person going to be suitable? For groups wise, I would say individually, it is much easier to get to know the person in front of you. Um, because you can ask them things that they might not want to say in front of everyone else. They may tell you things that they, you know, especially if they're meeting a group of people for the first time, day one, they're not going to say certain things in a large group of people that they feel more comfortable in a private room with you. Um, and you can also get down to the nitty gritty of the, you know, Why is this pain going on? What is driving this? What are those, you know, impacts, various factors they've had in life or not, or beliefs, whatever it is, right? Things that are driving their pain, how can we dig down and find those things out? Um, but you're also right in that I can't sit there and say, I know how you feel. I can't, I can't say that, nor should I say that. Um, it's not a great way of expressing empathy. And I think actually. Yes, it's individual is better for kind of working out the what is wrong and helping someone with a plan. Um, kind of the why they, why is this all going on? But I say for groups, you know, it's, it's like you have extra support for and suggest what you're going to do, because usually when I deliver, when we're delivering a group. We'll be talking through various management strategies. So let's say we're talking about, I don't know, um, pacing, for example, right? We're talking through the concept of pacing and they will be talking through it. And you can ask at some point, how are people who's tried this in the past? What have been your experiences? And they will always provide you got a decent group of people. Someone will say, well, I did this and it led to this and it helped because whatever. And the fact that it's come from them, the person who is like everyone else in that group, they can relate to much easier and they're more likely to take that in and go, Oh, that might be a good idea then maybe I can try that. They did it this way. That is much more powerful than me sitting there and bringing out a graph and saying, Have you thought about pasting before? What do you know? Here's a boom and bust graph, blah, blah, blah, blah. They hear it from someone like them, general psychological research will tell you they're more likely to then do it or give it a go compared to if it comes from us, because they can relate to that person more. So I think that part really helps with the, the implementing the strategies, if you will, the change. There are even programs out in the country now, and we're trying to do this as well, where they will have ex participants who have done well. Ex participants helping the delivery of the program themselves. Um, and I think that's, some areas are doing it now, just a few. But we're trying to do that. Um, as you can imagine, there's various red tapes you have to jump through. Um, but that will just add to the making it relatable and just helping them get as much out of it as possible.

the Ability to just have somebody who's been there done that just the validity in that patient's eyes of, of their maybe words, even though obviously our words are well intended and founded in the best science we can found it on and those things, it's just hard, you know, to, to equal the authority of status, I guess, of somebody who's not that we don't have our kind of authority, which I don't even like the word because we were more of a teammate guide by the side versus this paternalistic authority who's ruling over them. But Um, as far as they look at as somebody who's got knowledge that that really holds high, you know, regard in their mind, as far as somebody who's been there, done that type of thing. I love the fact that you're doing the teaching and communication. I firmly believe you've probably heard that communication should be looked at as an intervention. We sometimes look at as this like secondary soft skill type thing, which, as I'm sure you're well aware of in your in your training and your teaching. It's much more. It's not soft at all. It's very hard. It's challenging. And it, and it, it varies human to human. Your, your interactions are always going to be unique. I'd love to hear before we get into some of the difficult conversations that will help the folks that are listening out there. I'd love to hear your perspective on communication. Of when, how, how you looked at it as a physio student when you're coming through university, I know, you know, for me, it was that was again the secondary thing. I didn't even really think about communication. I was just ready to learn how to do the best exercise, the best manipulation or all those things. How did, how did that kind of transpire for you? How did that kind of progress over your from your physio university days to now in practice? How's that kind of transformed, I guess.

Um, so I suspect like most people listen to this going through uni, I was taught, I don't know, fairly early on what to say or what to ask. So you're taught fairly on how to, you know, what to ask in your subjective, right? What makes it worse? What makes it better? How was your sleep? Who's at home with you? Tell me your story, all that stuff. And as a student, I was fairly blessed in life that I think. Whether it's genetics or just experiences I had actually kind of forced me in a way to make sure I could build, you know, have a decent conversation with people. And I remember my last placement, my educator, I, the actual placement itself was a musculoskeletal placement. Um. I, if you'd have asked me as a student, did I like MSK? I was like, no, not at all. I don't like this. Um, and if you had told me what I'd be doing now as a career, I would be very surprised, but my educator, he had, whether it's best word to use is charisma or just a presence of, when he spoke to people, people felt listened to and that he was being attentive and cared for. Didn't really make much sense, you know. put too much together at the time, but just seeing what he was doing wasn't drastically different to what anyone else was doing, kind of exercise and treatment wise. It was just, but how he was just as a person with them seemed to make the big difference looking back at it now. And then as a, between qualifying and then starting work, um, my, uh, father in law was talking about a book. I'm sure you and many people have read called how to win friends and influence people. And, um, I read that and that was really the thing. That made me, that, that, it's that click, that thing. They never taught me this, but now I get why the educator was making the difference. This is the thing that I just felt, ah, yeah, now this I can grasp. That's still my favorite book to this day. Um, I know you started then incorporating it more and more, just the basic thing. There's nothing particularly technical in it at all. Just basic things of listening, smile, um, validate, etc. Uh, As I was kind of going through the early years of my career, um, I worked in the sports and I worked in martial arts and my judo and mixed martial arts. One of the things we're trying to implement there was doing things that they can try and reduce the risk of their injuries. And the big dilemma was Actually getting them to do it. You could tell them, you could show them what to do. We knew what they could do, but how can we work with them to try and implement these things? And then started reading more and more various other things around kind of behavior change and this kind of communication stuff, not beyond just what we say, but the nonverbal stuff as well. Uh, and then it was really, I'd say a few years into my career when I started getting interest in people with persistent pain as well, um, I read Louis Gifford's books, which I think many people have, and it's all kind of cemented that and then, um, when I started doing the teaching is really when I realized, Oh, there's a lot as physios or physical therapists that, you know, we're taught what to say. We can be in patients generally like us right compared to other professions We have an idea of the basics, but the harder things that you know what I was then going through in the medical school with the breaking bad news that They were covering things. I wasn't doing the death and dying the hard those hard conversations Managing anger, etc. Those are the things I thought, where is this for us? Um, and I think you're also right. You as a student, you realize, you know, it's important, but you're also worrying about all the treatment things you need to do, making sure you do your assessment right. Our medical students are also, front of their mind is keeping the patient in front of them alive. Um, I think It's only when you qualify and you've been doing it for a certain amount of years that you suddenly go, oh yes, that, that, how I talk to them, that's the thing that makes the difference. Yeah, you, you learn how to assess, you learn how to treat, you go what to do, but it's how I am with them and I don't know whether it's a few, four, how many years it was. That's what clicked and I think it's with the schools and the teaching that's made me think, oh, there's this extra stuff that could we could benefit from as well.

I think we've, most of us have similarly had that journey where it wasn't emphasized in our practice, you know, in school, as you mentioned, we understood. Yeah, it's important. I need obviously be able to say what I'm doing and why I'm doing it to a patient, but it never really took on the importance of man, you know, how we communicate, how we are contextual effects, all those things surrounding interventions that often drive a lot of change more than what we thought. Um, and they're super important. And I know for me that, yeah. You know, it was resulted in me chasing more interventions and tools in the toolbox, that whole thought process and falling flat with that. And it wasn't until, you know, reading Gifford's books and having a pain science course and kind of reigning in my thoughts of the manual therapy's ability to save the world that, you know, it was, you know, and patients humbling me over and over and over again when I didn't really take into account how important their story was and be able to get, co create that narrative. With that said. You work with a lot of difficult conversations from day to day in a pain clinic. That's just part of the day to day operations. Um, one I thought we'd touch upon that you had mentioned as we were kind of leading up in the podcast, which I think folks could benefit from is these ingrained beliefs. And maybe you choose which, which one everyone you think is the most common. I think sometimes it's just like, this is this cognitive fusion concept that, you know, acceptance and commitment therapy speaks to, like where folks are just fused to their thoughts and beliefs on Future prospects, and we could probably name them, but I'm curious if you could give some maybe an example of, um, some of the ingrained beliefs and maybe how you approach those in practice to kind of open up a conversation to maybe move people in a better direction, I guess.

Well, I guess at the moment, a lot of ones that are trickier that we see. So in the pain clinic, we're seeing a lot these days of widespread pain. Um, the, the, the days of us seeing, and I call them the kind of the pituitary cell of impatience, but the classic back pain, scared of moving, had the scan, shows you changes, fearful, all that stuff. We're seeing less of that now because I think general physical or physiotherapy is getting better at managing with them, but we are seeing a lot of widespread pains. And so most, a lot of them getting diagnosed with either this fibromyalgia or chronic widespread pain diagnosis. And I think a hard, some of the tricky beliefs with that is when someone says they've been online, they've spoken with someone and they said, It's not fibro. I think something's been missed, or I think it's, it can't be that, right? This fibro diagnosis says it's all in my head, or I'm making it up. That, and they're not, someone's at that point. That's, I think it's probably one of the tricky ones at the moment. And so what do we do about that? How do we work with someone where they've been given the diagnosis by a, a usually doctor or professional who's done a decent assessment, done the relevant tests, they've had scans, they've had some blood tests, they've had whatever they need to have done. Granted fibro diagnosis these days, providing you fulfill the criteria and there's no other obvious concerns for anything else, then that's how it's done. But let's say they've had, as most of our patients had, a decent amount of investigations. They say this and they feel, no, it's not that, it can't be that, they're just saying it's in my head. So how do I address that? I'll tell you now, the first thing I don't do is I don't flip, turn around the computer and go, well, Jane, you've had this scanned, you've had these blood tests, they're all fine, Jane. Facts don't change feelings. You know, we are, as humans, we naturally want to go, let me tell you, let me tell you why you're wrong. Here's some data. Data says this, therefore change your mind, please. Okay? Sadly, as you and I both know, Mark, that's not how humans work. Um, um. In fact, giving data to people, especially when they've got ingrained hard beliefs is almost one of the worst things you can do because it's almost likely to ingrain that belief further, right? Sometimes people call it a backfire effect or it has different names, but you could, you could apply that to this situation. You could apply it to political views, all sorts of things. You tell someone contradictory information to their firm belief that's very far away from where their beliefs are. They'll pick it apart, they'll usually have an answer. An answer that's something like, Oh, I don't trust that because of this. Or I don't believe in that because of... whatever it is. So, my first question back to them is always, What have you been told? Have you been told you've got fibromyalgia? Okay. What do you know about it? Or how did they explain it to you? Because whenever these, having these difficult conversations, whether it's beliefs or other things, I'd always start by finding out what someone knows first. And how they feel about it. Because it will, A, potentially save you a lot of time. B, you know, kind of what not to do in a way. So I was at a teaching like the other day and they were talking about functional neurological disorder and the physio who was delivering it said they saw a patient and they're going to start talking about FND and the patient said, Oh, please don't tell me about software again. Right. And so, you know, they told me there's the analogy of the hardware and the software for these kinds of things. Don't tell me I'm going to be like a computer again. So always find out what they know and how they feel about it, because that can easily guide you where you're going to go with this. Second thing to say is don't expect to change their beliefs there and then. People don't just change if it's if the belief is like on the fence. And. You know, they've had some, and they're not really sure it's ready to go, then sometimes data and just showing them information, for example, um, uh, a popular thing to do in physio world, and I'm sure we have various colleagues that do it, where they have the Degenerative disc disease on the scan right and the patient's a bit unsure It's about should I move or not and you bring up that graph which shows? Ah, yes, 50 percent of people your age have these findings right and they don't know about it at all and the patient goes All right. Okay, that's safe to move. Yeah, it's safe to move great move forwards but I would for ingrained beliefs I would not expect it to change in front of you because often people don't want to lose face, right? It's a bit embarrassing for someone to go, I'm actually alright, um, I need to go and think about it. So, once I know what they've been told and how they feel about it, then it's a question of, um, If you ask them what it say, for example, they don't believe in it. Okay. So what do you know about fibro? Well, I read this that that this okay I feel I've got this instead. Let's say I feel I've got rheumatoid arthritis and the person says And they've been they've seen a rheumatologist they've spoken with them. They've got no inflammatory features everything testing is. All the scans and stuff are fine. Um, and as I said to you earlier, just showing them the scans and showing them the blood results alone won't just make them go, Oh, fine. I've got fibro. So you could say to them, well, what did you make of that? When, when the rheumatologist said that your bloods and tests were okay, what did you feel about that? What were your thoughts? So, and. It may say, well, I, I feel maybe something's been missed or maybe it's this or that or otherwise. And I, I liked your, you were talking about ACT there earlier. I, I'm a big fan of acceptance, commitment therapy as well. I think ACT is a, uh, someone once described to me a nicer CBT. CBT is much more, you have this thought, Oh, you've now done this, your thought is wrong. Well, ACT is more. You've got this thought, is it helpful? And I've ever since, I've always had that thought, is it helpful? So we apply it in this situation. You've had this, they've shown you these tests, you know, they're having this feeling about the belief and thinking that maybe something else going on. Um, they say they've ruled out everything else. Is that belief helpful? How does that, and you'd ask them at some point in your assessment, what are your values? What are your goals? Is this feeling going to help you move towards that? Um, and again, you're not expecting them to suddenly go, oh, okay, fine. I'll change. I'll do this. Whatever. It's just putting it out there. My boss calls it dropping a seed. I quite like that idea as well. You're just floating it out there for them to reflect and think about. And then what they're going to need this time, they will, they will be aware if you've just clarified already that the, everything was okay. You can tell them about, you know, fibro, whatever the condition is, but only tell them what they want to know. So I always ask, what do you know? What have you been told? Da, da, da, da, da. Okay. So they've mentioned about this fibro. Let's say you've asked them, what do you know? They probably say not a lot. Okay. What would you like to know? Right, I'd like to know about what are the symptoms. How does it happen? Okay, well symptoms are this, it happens because of this, and then it, just pause, don't, again, don't expect them to go, okay, that's my diagnosis, I agree, blah, expect them to go, alright, hmm, and then if they want more information, give it. I think the key thing is, if people feel like they're being pushed, like we're pushing them into a diagnosis, we're pushing them in this direction, whatever it is, they're going to push back, right? Thank you. They're gonna go, no, I, well, tough, I finished it. So just leave with them in sync and then you're going to see them again, however long your follow ups are. So I view them maybe a few weeks, a month later. Okay. We discussed this last time you asked for this information, which you said you'd go away and read. How did you feel about it? I think if you can avoid pushing, give them time. The key thing with any beliefs or behavior is people need to change. It needs to be their idea. You can facilitate that, then you can guide and edge, but you can't change their mind for them. They need to come up with the idea themselves. I'm being, I realize I'm being slightly vague with this, but the thing is, as you, as we said earlier, we treat people, not patients. So what will facilitate one person's, um, change in beliefs will be different to another. And I think whatever you can do to work with them individually, when their understanding and their needs. then you're more likely to help them with that. Um, at the end of the day, they may need a medical person in a suit to sit down with them and say, again, look, we've done this, we've done that. It's still this, this is it. That's fine. Okay. But if you can be, you said coach earlier, Mark, I'd be the coach with them, the support, working with them, not against them. I think that's the key thing. Sorry, I was yapped on that for ages.

It was good. It was good. I, I, it is. It's, it's interesting, you know, trying to like, and you can hear it in your discussion. There is like, you're trying to create and sculpt a conversation, you know, and it's, it's like, you're, you're letting the patient come to these conclusions on their own, but you're creating a conversation that steers that patient to kind of look, you know, their thoughts and what they're, what you're kind of having them explore and seeing if they line up and their beliefs and. Um, I, I find that, you know, immensely challenging, but that's what I find fun in the clinic is like, how do I dent these beliefs? Um, how do I kind of get through to this person? You know, one, you got to understand, well, where they've been, what do they know? What all the things that you spoke to, um, and then, you know, with every person, as we mentioned already is so unique and has a unique life experience that brings them to your door. How do you, what, what, how do you steer conversation to have them? Hopefully question things. But like you said, and you're, you're, uh, it sounds like your supervisor about planting that seed or throwing that seed out there to just see if you and if you can get enough seeds out there, um, then hopefully one germinates into something that might move them in a positive direction. I really like that. The, the other thing that I think communication and difficult communication is when the emotions enter the treatment room and those often accompany pain because pain is a very emotionally charged for, for. Obviously understandable reasons when lives are really changed in a significant way and not a way that obviously most of us would be happy about when we're not the person we want to be and all these things are kind of feel like have been taken away from us or the biographical suspension type thought processes with it. When somebody comes in like very depressed, we'll say like where they're just, you know, struggling and those are often the people when you're trying to like kind of go act well, well, you know, valued goals. Where are they? What are they? What do you want to do? And they're just like, nothing. You know, I don't really have anything. What, what, what do you think with depression? I mean, that's just one option or one thing that might happen when you're asking for goals and they're just kind of blankly not able to really come up with things mainly because they just don't see any Goals to be had with their current, current situation. But, uh, what is your approach when you, when you deal with somebody who's dealing with that kind of significant depression?

A. Have a good box of tissues nearby.

Yeah,

Um, Um, I would say B. We usually like to ask lots of open questions, usually with our patients. So, you know, tell me what's happened with your story? How does this affect you? What are your goals, as you said? But, uh, and this is something I picked up when we started doing the, teaching about certain psychiatric stuff. When someone is very depressed, Or even, you know, into the suicidal range, actually closed questions are better. They're more, they will find them easier to answer compared to open questions. So if someone's been through a very distressing time, you know, whether it's related to their pain or something else has happened in their life, very upset, very distressed, as you say, really quiet, really slow. not looking at you at all, looking at the floor, you know, then actually close questions are basically the yes or no answer. So would you like to talk today? Yes. Um, has the past few weeks been really tough? Yes. Um, you, we're lucky in our situation. I can see to give an example. Uh, a few weeks ago, saw a lady, she, speaking to her on the phone, she says, I've got something to tell you. I said, okay. What is it? Um, my husband left me after 30 years, suddenly, um, and thankfully I knew in advance because I could see on the GP notes, but you know, someone's partner of 30 years has suddenly left them, right? Someone, it's for someone else. And, um, You know, at that point, they're very upset, very, you know, quiet, is now the right time to be making a big paid management plan of various tools and exercises and whatnot. Of course, not you're shaking your head before I even said it. Um, I would say what the closed questions, thankfully she was, um, she was a few weeks after so it was more talkative again, but you know, if someone you're really struggling to get any conversation that she closed questions work. Take your time. Allow pauses. Um, you know, if I would say, whatever you, however long you can tolerate a pause for, try it. Okay. People will fill gaps. We as humans want to fill the gap. If someone sits there for long enough. Not say anything will eventually want to go Fill it so can you you know allow them to have that time to fill it and a phrase? It's I've heard used in the past few months Have you ever heard of the phrase sitting in the mud with someone

I've heard something similar to that.

Past rooms are complex exactly remember where I started here in it, but Essentially, if someone's going through a very distressing time, so we'll take the example of that lady. Husband's left her after 30 years. She's very upset, very stressed. Life has been flipped upside down. We've already said, it's much, not much, isn't the right time for me to be going on about all the various pain management tools. And am I going to be able to, and in that half an hour, be able to say or do anything that's drastically going to change how she feels? No, of course not. I can't change that. Nor is the patient expecting me to change that. You know, you know, most people, you know, if they're going to see their physical therapist or physiotherapist, they know that they're not expecting us to do three hours of counseling or 10 sessions of bereavement counseling, whatever it is. Okay. They know that that's, we're not, yes, we're psychologically informed. Yes, we're taking a biopsychosocial approach, but They're not expecting that from us. They're not expecting the, to do a whole hour of, um, cat therapy, whatever it is. But sitting in the mud implies listening, which we well know by now is the most important thing you can do. And then just being with them, empathizing, you know, listening to their story, acknowledging what you've heard, and then some form of. Demonstrating empathy, whether it's something like it sounds like it's been really difficult. It looks like you're going through a lot at the moment. Whatever it is, whatever suits the patient and the situation at the time. And you're just being there, take your time, speak calmly. Give them a little bit of space as well. You know, if you're going through a very distressing time, the last thing you want, I presume the last thing you want, is a... Therapist, in my case, 6'2, probably can be larger than most patients I see, sitting there close to them, looking at them like that, right, probably quite intimidating, not what they want at the time, give them space, give them time, and if, if you can't, don't do anything that time, don't do anything, just be there, you just being there, listening to them and letting them cry and get it out, maybe more than they've had from anyone else so far. And that's okay. I'm blessed in my pain service. I'm not in a rush, right? We're not expecting any more investigations. We're not expecting any of the things that have a time scale on it. We're with them, not forever, but for as long as is suitable for the input and provide them making progress. But as you say, it's not the right time to implement all those strategies, but maybe just feeling supported helps build your reports when they come back. Um, and then they'll come back a month, two months later, and they've had time to grieve or whatever it is. They get support they need. And if you need to direct them to any psychological support or colleagues you have, then do. And then when it's the right time, they're then at a place where they can re engage. And they feel also, if something comes up later on, they can open up to you again. And tell you something that they may not have told you in the past. And it does happen occasionally. People come out with things. So a few appointments in that actually they didn't tell you initially, but they didn't tell you anything. Ah, maybe there's a big piece of the puzzle. Why this is persisting when it hasn't. It's fairly, you know, it's fairly simple things. Listen, empathize, given space, given time. I think we may be as clinicians put pressure on ourselves that I have to make this person feel better. Okay. Yeah. Pain, but also emotionally feel better. If someone's in the mud, I call it sitting in the mud, not pulling them out of the mud, because someone needs to have that human time to grieve or whatever it is they need to express. So sit there with them and they'll get out when they're ready. You can then, you know, you're there with them as they're getting out. I think if we just acknowledge that, be there at the time and that's maybe all they need, right, they don't need anything more than that. And direct them if needed, yeah. Um, And then carry on, and they'll catch up, follow on with them when it's suitable.

I like what you said with the, the silences.'cause I, I know for me personally, it was very challenging not to wanna rush and fill those silences, but just. letting silences happen and let people kind of process things and let people, you know, often they'll pick up a discussion. Sometimes maybe after some silence, you can have a gentle cue to, you know, like you said, this looks like it's really hard for you. I can imagine this must be very challenging and you just kind of let people get it out. And this, this, I'm also very fortunate where I'm not pressure productivity and in things that unfortunately a lot of colleagues that we talked to are where sometimes the most valuable session can be them just kind of letting. that stuff out, feel listened, feel heard, you know, be validated that you're not just rushing them to get your units. You're a human who cares about what they're going through. And then it may open a door for some discussions, as you mentioned already, where you can start really uncovering some aha's like, okay, now I'm starting to see how these pieces fit together and what might be driving a lot of the challenges with pain and things that they're having. We got time for probably one more emotion because this, you know, there's obviously a multitude that arrive in the treatment room from day to day, but common one that I think people see, and I know we recently just finished up with a student physio in our clinic and he, he had a few episodes, which I, I love being able to see a student. Cause 20 years in 10 years and like yourself, you kind of lose sight of what it felt like and what you were thinking at that time, but to have students and kind of see, okay, yeah, I remember. Yeah. Feeling the same way and having those same experiences, but anger was the emotion I'm thinking about with Patient patients coming in maybe saying some choice words really frustrated with you know, maybe the management or not being heard. I'm just curious What what's your approach when somebody comes in with that type of emotion in in the room?

So, I was never, but Mark, tell me if you, were you ever coached, or just taught, in your training, my anger management skills at all?

No, not not nothing to do with the physiotherapies uh things I mean, I remember Coaches in sports say mark you need to tone your temper down That was about as far as far as I ever got in anger anger management for sure

Out of interest, when they said that, did you actually, did you turn your temper down at all?

No, not at all. I mean, that's that gave me zero skills. It was just like, yeah, you got to temper do something about it. Well, what do I do about it? I mean, it was just like, it's like, you know, point out a problem with zero solutions to the, to the problem.

So I will say anger is a normal human emotion to have. However, when we all think of anger, we're not so much thinking of the emotion, we think of the expression. It's the expression that makes some of us go, like your student, God, because if someone, it's the kicking off, right? People can be silently angry. Okay. Um, just people don't say anything. They just zip it, you know, um, good old silent treatment is various relationships you might've experienced. Bye. When they make one that makes us all go worry is when someone's Aggressive best word to use or verbally angry like and I'll also add That I can only say this in my experience I'm just observing others, but very rarely if a patient's angry, especially if you've not met them before Very rarely are they actually angry at you the clinician. They may be angry about other people they've seen experiences they've had the traffic getting in, who knows? Okay. But as I asked you there earlier, you said, they said that thing, your temper didn't change. Worst thing you can say that probably will cause the opposite. When, I mean, your experience Mark, has the phrase calm down ever actually led to anyone calming down at all?

Uh, that would be a negative. No.

No, not exactly. Um, usually causes the opposite calm down. You want me to calm down? Um, and with that, If possible, try to avoid labelling them as angry. You tell someone they're being angry, they're going to be more angry. Okay? Um, so I would aim for different adjectives. Frustrated's a good one to use. Um, uh, this sounds like it'd be a difficult situation. Um, but, Avoid saying you sound angry or sound, you know, this is your king angry here. Okay What would I do? Providing they weren't being abusive to me I Would let them go Let them get it out right, let the steam vent and just and they will Come down over time and we said about silence earlier and pauses A pause, if, if you can, they're also in a pause go, and the balloon that's gone up will back out again. And half the time at least just letting them go, they'll come out of it. I even remember, saw a lady, very frustrated at something, again, not at me, I'd met her for the first time. She was very angry about something. She came back next time I saw her, she said, I'm so sorry, I was like that. So that's okay. What they've been through often can justify the anger, but how it's expressed may not be justifiable. Um, I will say to people, yes, patients may be angry, but you do not have to tolerate abuse. If you don't feel safe or it's not being productive, don't keep it going. Don't try to resolve it. If you feel like you're just going around in circles, it's not worth it. Okay. For you and for them. Try to come back to it later if you can, or do whatever you need to do to close it. But certainly, providing you feel safe, providing you feel you're getting somewhere, and actually letting them go, empathising with them, um, direct, if they need to complain or do anything, then direct them to where they can. Um, and again, although I was saying earlier, it's never, most of the time they're not angry at us. I will say to people, if they're angry at something that's happened with a different service in the hospital or GP or somewhere in the NHS, I will say, classic line is, I know this wasn't my fault, but I'm sorry X happened to you. Okay. And an apology, even though they know it's not your fault and you had nothing to do with it, even just a gentle apology and acknowledging that can often help. Get them on board as well, get moving forwards. Um, I think the key, the key thing I will reiterate though is, if you don't feel safe, don't stay there. But, from my experience, and it may just be because I'm a six foot two male, but it's very rare that I don't feel safe at all. Um, but if you don't, you do not have to tolerate abuse at all. And if you feel unsafe, just either leave or whatever you need to do to feel safe.

That's great advice. I think, uh, thankfully, I haven't had any times where I've felt in danger myself, but you hear stories. I've had definitely heard colleagues talking about things where Exactly. Like you said, it just, it wasn't going to be fruitful, you know, had to, you know, maybe stop the conversation and, and, you know, kind of move in a different direction. But, uh, Ben, I could talk, we could talk for hours more about this stuff. I I've really enjoyed your perspective. You can tell, you've had these conversations on a regular basis and obviously you're teaching people about these conversations on a regular basis and it shows. Um, so I greatly appreciate your expertise today and, uh, really appreciate your time.

Well, thank you for having Mark and I'll be happy to talk again with anyone else listening whenever.

We're, with that said, where can, where can folks locate you online if they wanted to kind of post some questions to you or, or kind of follow up with some of the things they heard today?

My uh, my social media is all the same across Twitter X as it is now and Instagram and I think TikTok. Uh, it's simply be wybrow physio. Um, and you just search that or if you just search Ben Wybrow into Google, I'm sure my name will come up. There aren't many of me. Um. Thank you. And that's an easy place to find me. I'm easy to message. Um, and just any questions or queries, that's who I am.

Yeah, and we'll link, uh, Ben's, uh, social media accounts on our show notes so you can get in touch with Ben. He's definitely somebody who lent some good, uh, uh, conversations online and we're somebody to pick his brain and, and get his input on things. So again, Ben, thanks for your time today. For those of you who are listening. Uh, we'd love if you could subscribe to the podcast on wherever you're listening, or if you're watching on YouTube, we'd love if you could subscribe there as well. So maybe we can spread some information to some clinicians who are struggling to have these types of conversations in their own practice. Uh, but we'll leave it at that this week. We will talk to y'all next week.

This has been another episode of the Modern Pain Podcast with Dr. Mark Cargilla. Join us next time as we continue our journey to help change the story around pain. For more information on the show, visit modernpaincare. com. Also visit the Pain Masterminds Network on Facebook for free education and resources. This podcast is for educational and informational purposes only. It is not a substitute for medical advice or treatment. Please consult a licensed professional for your specific medical needs. Changing the. A story around pain. This is the Modern Pain Podcast.