Throughout our lives we are modelling behaviours that others are observing, whether we are aware of it or not. This modelling can plant seeds that can cultivate behavioural change for better or worse. In a recent clinical coaching session, we discussed how we as clinicians’ model behavioural change for the people we are helping. During this session I was being lazy with my explanation of case study, Laura (coaching faclitator) pulled me up with “Mat! enough of this psycho babble bullshit, what are the processes at play?” My initial reaction was to get defensive, I observed this in myself, defused and crated space from my automatic responses, gradually working through my explanation. Reflecting on this, I was being challenged, but in a good way, as this is how I learn & grow. Over this month I have taken more notice on how I model change to the people in my life.
Recently I have taken up singing lessons, no not to become an amazing singer, but to help my stutter and communication skills. I had no idea if I could sing or not, as I had done almost nothing in this space before, except for singing in car. I have practiced every day, gradually improving week to week. Without realizing it over the years I was talking in a very narrow deep range as this was my safe range and less likely to stutter, now my natural speech has a much larger range and freedom. My kids have watched this process unfold, I have modelled to them the importance of learning new skills, values, persistence (even when there was negative criticism) and constantly being able to grow at any age. It will be interesting watching the kids over the years and seeing what behaviours I have modelled for them, some that are helpful and probably some that are unhelpful.
In the clinic I have been taking more notice with my interactions with people. For a long time I have used open postures, curiosity and practice a lot of what I teach. Self-care has been a big part of what I do over the past 10 years, when people ask me what I do to look after myself I will openly talk about my journey through depression and pain, what coping strategies I use, including exercise, mindfulness, learning new skills, helping others and how I incorporate this into my life. The people that come to the clinic will see this with my interactions and may plant some seeds of change.
Last week in the clinic, I was asked how I was going? A part of ACT (acceptance and commitment therapy) when appropriate is some self-disclosure (but not too much) to help facilitate change and build connection. I talked about the covid pandemic and my mental health struggles. This openness allowed the person to open up about her own experience with depression over the last few months. This person was not keen on seeing a psychologist as she was sick of going through her past and it wasn’t very helpful. I talked about my own experience with counselling, how I use it as a way of learning coping strategies that when shit comes up and it will, I have a set of skills that will help me to navigate through this. I was reframing how seeing mental health specialist can be beneficial. The session finished with me giving a card and referral to a counsellor, with next session hopefully the openness is there, and we can check in on how she went.
Another lady that I have been seeing on and off for 20 years, was a bit stuck and bored, she was showing signs of low mood. She really enjoys being creative and learning new skills, I chatted about myself started singing lessons even though I didn’t know if I was any good and reflected on the values of why I was learning to sing. The next session this lady had singed up to choir in her local area and was excited about singing with a group. This was bringing in elements yearning for human connection, learning a new skill and having fun. We can unpack the values of this over the weeks to come.
I have been modelling behaviours throughout my life, some I have been aware of, some I have not. I am now taking more notice about my interactions and the impact it has. Doing clinical coaching is an important part of clinical work, as it allows me to grow, challenge what I think I know and occasionally getting a kick up the arse when it’s needed, to push me to do my best. Now after consults now I am reflecting:
How did I model behaviour change?
How affective was it?
What other ways could I have modelled change?
Embody what you value, infuse it through your life, this will flow onto others.
Last year I did an interview with a person that was suffering with debilitating pain, during the interview she reflected that I was curious to know more about her whole experience. I created a space where I was open to her whole experience and areas of her life that she has not explained to other MSK clinicians. She was intrigued to know why I wanting to know more, how does this fit with her pain? After exploring her experience for 90 minutes, we then started to help her make sense of how all of this fit together. We did this through careful exploration of her emotions, beliefs, environment, and her bodily responses and how these may interact together. She was starting to reconceptualise that what she was going through was much more than damage equalling pain.
The mission we set for her was to explore her back pain but in a curious way, where is it, how does it feel, what thoughts are happening and what would happen if she relaxed the body and stopped fighting it. The processes at play are present moment awareness, self as context, defusion and a willingness to be with pain. We were playing with context, helping to cultivate a shift in her relationship to her pain. The next week she came in happy and excited, she had taken photos of herself bending with bracing and protection, then photos of her moving in a relaxed mode, the change was seismic. We can hypothesize that there was a large expectation violation triggering a lot of prediction error, which triggered updating of her models of the world. The range she was moving through was life changing for her, the reconceptualization that she could move again and do what she valued most.
What we were seeing here was a person starting to make sense of her experience through play and experiential learning in the context of her world. “Facilitating a space to create an optimum environment to explore” (Rathbone, 2022). What we commonly see with people in pain, is they loose flexibility in life, move less, engage in activities less, withdraw from social events, trying to control their environment to protect themselves and decrease error in their system. This is probably a good strategy in the short term, but not so good in the long term. Having an environment to encourage people to explore their world again to cultivate more curiosity and flexibility is really important.
“When we’re fully present with our clients, open to whatever emotional content arises, defused from our own judgments, and acting in line with our core therapeutic values connection, compassion, caring and helping, then we naturally facilitate a warm, kind, open, authentic relationship” (Harris, 2019)
Creating this space to explore and play will hopefully flow through their life, giving them permission to explore their world again.
“An agent that is able to remain at the edge of order and disorder will combine flexibility with robustness” (Miller, Reitveld, Kiverstein 2021)
“Frequenting this edge of criticality requires that predictive organisms are prepared to disrupt their own fixed point attractors (habitual policies and homeostatic setpoints) in order to explore just-uncertain-enough environments that are ripe for learning about their engagements” (Miller, Reitveld, Kiverstein 2021)
Just the right amount of curiosity about our world will allow us to gather information on affordances in our environment, giving us more ways to respond to our ever-changing world.
In the clinic let’s give people a space that invites them to explore their experience and what it means in the context of their world and how they interact with their world. Slowly cultivating a curiosity to explore and along the way fostering more flexibility, so they can adapt to whatever the world throws at them and engaging again in what makes them, them.
Miller, Reitveld, Kiverstein, The predictive dynamics of happiness and wellbeing, Emotional review, 2021
Rathbone, Beams, Le Pub scientific, Making sense, 2022
In our daily lives’ movement allows us to interact with the world, we express who we are through valued occupations, the things we need to do and want to do. These valued occupations are vital to give us a sense of self coherence, where “habitualized notions of self” can continue to be expressed” (Thompson, 2019). Chronic pain can be a major challenge with how you interact with your environment and lead to a loss of self-coherence where the person feels they cannot do the things that are important in the world. This can lead to a self – discrepancy when a person feels the failure to fulfill ones hopes and responsibilities (Kwok 2016). A study in 2016 showed a close relationship between self-discrepancy and adjustments to chronic pain (Kwok 2016).
10 years ago, when I was suffering with pain and depression, I was withdrawing from life. Experiential avoidance was becoming my dominate behaviour, trying to protect myself from doing further harm. I couldn’t make sense of where I was at, why I was responding the way that I was responding. I was interacting with my world less and less, losing flexibility in life, losing contact with the things that made me, me. “Our perceptions are thought to reflect the utility of self within an environment” a so called ‘neuroeconomic’ vantage point” (Tabor 2015). Pain is a high-cost experience (Tabor 2015), with my internal models of pain equalling harm, moving less and protecting myself was a common sense approach. But I was developing a self-discrepancy (Kwok, 2016), where my past self the guy who was active playing sport, go wood chopping, intelligent, go fishing, gardening, I couldn’t clearly see anymore, and I was lost. I was now becoming my undesired self, weak and sick and I was creating my own hopelessness and stuck in a cycle of avoidance.
They day I decided to start using my body again, in spite of my pain, was the day I started to form a new self. Movement became a vehicle of change, where I was challenging my representations of who I was by doing valued occupations. In this time, I don’t think strength was a huge factor in the change in me, it was changing my relationship to who I was, that I was still strong, and I could do what I loved, I was not broken. I was creating more movement variability in my body, that it could do more and that I wasn’t in danger. We embody behaviours so just changing the way we think is not enough, we need to challenge embodied behaviours and it’s the doing that creates change. Changing the way we are sampling our environment, while continuously updating models of our world and our inferences of self.
When giving out movement-based strategies let’s explore with the person how their pain is affecting life, what are they doing less of? What are they doing more of? And why? What is the importance of these occupations to them? Let’s try to include more valued activities into their life, to build a bigger life around the pain of things that make them, them. It may not look exactly that same as what it was before, but if they can express values through these activities, they will be able to form new representations of self and hopefully make pain less of a problem. Movement is a great way to cultivate change in so many ways, lets increase
Thompson, Gage, Kirk, Living well with chronic pain: a classical grounded theory, Disability and rehabilitation, 2018
Kwok, Chan, Chen, Lo, The self in pain: the role of psychological inflexibility in chronic pain adjustment, Springer, 2016
Tabor, Catley, Gandevia, Thacker, Spence, Moseley, the close proximity of threat: Altered distance in perception in anticipation of pain, Frontiers in Psychology, 2015
Three years ago I was sitting back in a workshop on psychological interventions into pain, the speaker asked us to turn to the person beside us and speak for one minute about the positive attributes of one of our patients. The catch was, it had to be the client that when you see their name in your appointment book, you just sigh and feel drained before you have even seen them. My partner went first and talked about her person for the minute and spoke beautifully. When it was my turn, I went to open my mouth to talk about a lady I had seen in the clinic to say something positive, and nothing came out. I sat there in silence for the whole minute, I was horrified with myself that I couldn’t find the words to say anything positive. My judgements and internal models of this lady meant i was not seeing her as a rainbow ( a beautiful and unique gift of nature) but as a roadblock (Harris 2019) . This was a good lesson for me to not just focus on the negative with patients but try and see the light. Now when I get stuck with a patient, I ask myself the question Do I see this person as a rainbow or a roadblock?
After a new person has come in to see me in the clinic, I like to work through an ACT case formulation worksheet to allow me to better identify the different processes that may be maintaining this person’s predicament, in the context of their world. One of the questions near the end that I love and hate is- MY PERSONAL BARRIERS? (What difficult thoughts and feeling show up for me, regarding this client?). I also ask myself further questions:
What biases do I hold?
How am I perceiving this patient?
Can I hold a safe space for this person?
Do I have a preconceived internal model of this patient?
Is it me who is the roadblock? and stopping this patient from moving forward?
Over the years practitioners have written in their notes “patient was not compliant with their exercises” or similar, shifting the blame onto the patient for not getting better. When this happens, we need to sit back and reflect, how can I better cultivate an environment of openness, non-judgemental (or at least minimal judgement), to give this person the space to explore their experience? Reflective practice with yourself is a really challenging and important aspect of care, to make sure I am giving the person the best environment to flourish and grow. When you become stuck with a person ask yourself the question do I see this person as a rainbow or a roadblock? A rainbow is a unique and beautiful work of nature. Can we truly appreciate the gift granted of working at a deep level with our fellow human beings (Harris, 2019)
Harris, Act made simple, New Harbinger publications, 2019
A few years ago, I was treating a sweet old old granny, she was one of those granny’s that would make you cakes and hug you tight until you couldn’t breathe. She was laying on the table, looks at me with sweet innocent eyes and said “I have a vibrator at home should I use it?”………………. I looked at her and said, “If you feel the need to use one, then use it”. Of course, I knew she was talking about a handheld massage device to help with her pain. I realised we had 2 different frameworks and understanding of language, due to our age, demographic and the fact that my mind was in the gutter, and it was a deep gutter. I could have used language to better synchronise the two models, but the filter in my head said this was not OK, so I just left it (Yes, for those who know me, I do have a filter and I occasionally use it).
Over the past few months, I have been doing a course The Problem Of Pain with Mick Thacker and Laura Rathbone. This course has challenged me on every level, and I am constantly reconceptualising what I think I know. When I started this course, I would pick up a paper on predictive processing and struggle to read it because I didn’t have the schema, understanding of the language and how it all fit together. Fast forward a few months, I can now read and understand these papers better, as my models and schema are being updated as I go, but I feel I needed to strip it back further and get a deeper understanding of the language, so I started a glossary where I am picking out the key terminology and processes and writing a definition that makes sense to me. If I don’t get a deep understanding of the schema and language, then I would always struggle to apply these concepts in the clinic and in life.
My starting point was going back to the laws of thermodynamics. I wish back in year 10 I had taken more notice during physics, instead I was thinking of cricket and girls, (actually, the girls didn’t want a bar of me, so just cricket). But also, I didn’t see the importance of learning it back then. Once getting my head around the laws of thermodynamics, it was time to dig a bit deeper into the language around Predictive processing, free energy theory, inactivism and embodied cognition. This glossary is still a work in progress, and I will continue to add to this glossary and expand. The heavy lifting here is not the finished product but is the work I am putting into writing it and understanding it. This may seem like a lot of hard work, but I love learning and translating this knowledge into the clinic to help others. If you are currently doing The Problem of Pain course and finding it hard keep GOING!!! When we struggle, is when we can grow the most.
Let’s finish with a quote from Mick
“If we are to accept the immense privilege of helping people understand their pain and how they can recover from it, then we are absolutely obliged to know what it is we are talking about and if that requires some serious work, then so be it” (Thacker)
(work in Progress)
Glossary- Predictive Processing, Embodied Cognition, Free Energy Principal, Active Interface
1st law of thermodynamics- energy can’t be either created or destroyed, but can only be transformed into another
2nd Law of thermodynamics- that entropy will increase in the universe, increase in randomness or chaos and increasing the number of states due to increase in heat will increase velocity of molecules and increase the amount of predicted states. With minimising free energy, we are working opposite to this and trying to minimise entropy and chaos and limit the number of states.
The Free Energy Principal– That any self-organizing system that is at equilibrium with its environment must minimize its free energy. The principal is a mathematical formulation of how adaptive systems resist the natural tendency to disorder. The defining characteristic of biological systems is they maintain their states and form in the face of a constantly changing environment. The environment includes both external and internal milieu (Friston 2010 )
Thermodynamic free energy is a measure of the energy available to do useful work. It emerges as the difference between the way the world is represented as being, and the way it actually is. The better the fit the lower the free energy. (Friston 2010)
The Bayesian Brain Hypothesis- The brain has a model of the world that it tries to optimize using sensory inputs. The brain is inference machine that actively predicts and explains its sampling of the environment and sensation (Friston 2010). This is achieved by using a hierarchical generative model that aims to minimise prediction error within a bidirectional cascade of cortical processing (Clark 2013)
Prediction Error- Reports the surprise induced by a mismatch between sensory signals encountered and those predicted (Clark 2013). Prediction error is the form of free energy
Surprisal- Implausibility of some sensory state given a model of the world.
Entropy- measure of disorder or chaos. “Is the long-term average of surprisal and reducing free energy amounts to improving world model so as to reduce prediction errors, hence reducing surprisal” (Clark 2013). So, the lower the entropy means we are lowering the long-term average of surprise and minimising free energy.
Posterior Probability– still reconceptualising this one
Inverse variance- trying to get my head around this one
Bidirectional Hierarchical structure- is that it allows the system to infer its own priors as it goes along. Is does this by using its best current model and one level as the source of priors for the level below. This allows priors and models to co evolve across multiple linked layers of processing so as to account for the sensory data. This induces empirical priors in the form of constraints that one level places on the level below and these constraints are progressively tunes by sensory inputs itself (Clark 2013)
So, long as the successfully predicts the lower-level activity, all is well, and no further action needs to ensue. But where there is a mismatch, prediction error occurs and ensuing activity is propagated to the higher level. This automatically adjust probabilistic representations at higher levels so that the top-down predictions cancer prediction errors and the lower level. (Yielding rapid perceptual inference). At the same time prediction error is used to adjust the structure of the model to reduce any discrepancy next time around.
Markov’s blanket- Defines the boundaries of a system in a statistical sense. We need boundaries to separate 2 things, or it wouldn’t be a thing. Any living system is a Markov blanked system and have Markov blankets of Markov’s blankets – all the way down to an individual cell, all the way up to you and me, and all the way out to include elements of the local environment (Kirchhoff 2018)
Kirchhoff, Parr, Palacios, Friston, Kiverstein, The Markov Blankets of life: autonomy, active interface and the free energy principal, Royal society publishing, 2018
Friston, the free-energy principal: a rough guide to the bran? cell press, 2009
Clark, Whatever next? Predictive brains, situated agents, and the future of cognitive science, Behavioural and brain sciences, 2013
Recently I read a paper on predictive processing and the dialogue of 2 speakers, A duet for one by Karl Friston. It got me reflecting on my own stutter and how predictive processing might help me get a deeper understanding into my interactions with others. Throughout my whole life the stutter has been present, through primary/ secondary school and into my adult life. It’s not the worst thing in the world but is certainly something that can affect confidence in social settings, public speaking & people’s perceptions of you.
In my first year out of university, I was asked to lecture in anatomy for a semester at RMIT. The strange part of this was if you met me in the hallway, I would stutter my way through each sentence but in the lecture theatre in front of 60 students I owned the space, and my stutter was not present. The enigma of my stutter was certainly frustrating, I did not give another lecture for 13 years. Then 6 years ago, I wanted to drive a networking group towards learning together as a group, so I decided to run presentations myself to inspire others to step up. I choose a nice easy topic ………. stress, pain and neuroplasticity to a group a health care clinician, what could go wrong? The presentation went well inspired me to continue to lecture and help other practitioners on their journeys. Over this time, I have grown as a person and my stutter is now far less pronounced, it will still show up if I am tired or I have had a beer or two, but overall, it’s a lot better.
People who stutter are often seen as “highly disfluent, they must also be highly nervous, anxious and inept” (Byrd 2017). Self-reporting of a stutter seems to correlate to listeners having a more positive model of the speaker and “respond more positively to speakers who use a neutral, non-apologetic self-disclosure statement” (Boyd 2017). I have also seen this in my presentations, when I give a self-disclosure statement about my stutter, the interactions with the audience seem to flow. When you give the statement, it is also important when, “A self-disclosure statement at the beginning of the dialogue received more positive listener comments than those presented at the end” (Byrd 2017). When people would come up to me and say, “they really enjoyed my presentation”. I would think to myself, they are just nice people because surely having a stutter makes it hard to listen to me! As it turns out having the stutter makes me more relatable, people really connect with me a real human and owning the space in a non-apologetic manner helps the audience view me as a strong and capable person.
When we interact with people, we have internal models that help us to predict upcoming linguistic input. Most people haven’t been around people with a severe stutter so lack the internal model to predict. “Findings suggest the listeners hearing sentences containing stuttering abandon prior expectations, possibly because they lack a speaker model defined by the presence of stuttering. In the presence of stuttering, listeners appeared to focus on the input itself instead of using prior knowledge to form early (erroneous) interpretations and increasing accuracy of sentence interpretations” (Lowder 2020). The self-disclosure statement may provide enough error to wright the sampling towards the environment- in this case words (Rathbone). This is pointing to the fact that precision weighting is shifted to more the sampling of linguistic content rather than the priors.
Another interesting aspect of the influence of self-disclosure statement is how a positive self-disclosure state can change the focus on the stutter. “There was no difference in actual percentage of syllable’s stuttered by the speakers, observers reported that the monologues preceded by a self-disclosure statement sounded as though the speaker “stuttered less” and “less trouble talking”. Thus, the use of a self-disclosure may reduce observer focus on the behaviour of stuttering and allow for more focus on the content of the speaker’s message” (Byrd 2017). This correlates nicely to what I see during my presentations, when the audience would report at the start, they noticed my stutter then after a bit they no longer notice the stutter anymore. What we are seeing I think is an updating of the internal models of you by the listener.
Unfortunately, “gender bias is strong with stuttering, observers rating females more negatively than males with character traits, regardless of self-disclosure statements” (Byrd 2017). We can see there is a blending of many inferences we make about a person’s identity and how this intersectionality can compound the negative biases about a person. Can becoming aware of this intersectionality in ourselves towards others, give us enough flexibility and space to wright towards error and influence precision weighting towards the sampling? Creating space for us to see the person that is in front of us with openness and care, no matter what their gender, race, class or disability. Below is a short video by the amazing Megan Washington, esteemed song writer and singer who will hopefully help facilitate a more positive shift in understanding around stuttering and gender bias.
Stuttering has been a part of my entire life, but now I am bringing acceptance to it, embracing its apart of me and what makes me, me. The person who benefits the most from a positive and non-apologetic self-disclosure statement as the “act of acknowledging stuttering indicates acceptance and understanding”. Reading these papers has allowed me to better understand the ways I interact with people and ways I can facilitate building better relationships.
Byrd McGill Gkalitsiou Cappellini, The Effects of self-disclosure on male and female perceptions of individual stutter, American journal of speech Language pathology, 2017
Lowder Maxfield Ferreira, Processing of self-repairs in stuttering and non-stuttered speech, Lang Cogn Neurosci, 2021
Friston, A duet for one, Consciousness and Cognition, 2015
Review by Mathew Richardson
The free- energy principal: a rough guide to the brain, Karl Friston (2009)
Recently I started a masters level 8 week course on the problem of pain with Prof Mick Thacker and Laura Rathbone. This course was going to challenge everything that I think I know. I like to challenge my knowledge, beliefs and translating this new knowledge into the clinic. The paper I am reviewing today is The free energy principal: a rough guide to the brain by Karl Friston (2009). My first thought was WTF is free energy becuase I had no idea. I love how the paper starts with “the free energy principal is a simple postulate”, while I am sitting there scratching my head thinking I don’t get it, am I dumb. I think my biggest hurdle with starting to understand free energy was, I was thinking of energy in its traditional sense, an example mechanical, heat etc and I had to shift this thinking………
The first big shift for me was looking at free energy from “an information theory quantity that bounds the evidence for a model” (Friston 2009), this shifted me to more a mathematical way of looking at free energy. “ When free-energy is greater that the negative log evidence or ‘surprise’ in sensory data, given a model of how they were generated” (Friston 2009). So, if the sensory data inputs don’t match the predictions coming down, there is a discrepancy in the data and the larger that decrepency the greater the free energy. Another term for this is prediction error.
Entropy: the average surprise of outcomes sampled from a probability distribution or density. A density with low entropy means, on average, the outcomes is relatively predicable (Friston 2009)
Surprise: or self-information is the negative log-probability of an outcome. An improbable outcome is therefore surprising (Friston 2009)
A biological organism will try to resist disorder or entropy and it can do this by minimising free-energy and decreasing surprise. It can do this by either updating its models or predictions or by changing the way it samples and interacts with its environment which is more congruent with the current predictions, all with the goal of minimising free energy and decreasing the discrepancy of sensory inputs with predictions. Thus, minimising prediction error to make sure the organism is well adapted to its environment (Julian Kiverstein, 2021).
“If we change the environment or our relationship to it, sensory input changes. Therefore, action can reduce free energy (ie prediction errors) by changing sensory input, whereas perception reduces free- energy by changing predictions” (Friston 2009)
Before reading this paper I was confused and just wasn’t getting it, then the light bulb moment of changing the way I was thinking about energy, from more traditional views to a more mathematical view. This paper has been another piece in this complex puzzle of trying to understand and make sense of free-energy theory, predicative process and Bayesian models.
Karl Friston, The free energy principal: a rough guide to the brain, Elsevier, 2009
Julican Kiverstein, Le Pub Scientifique, 2021
This year so far, has been a huge learning experience for me, both on a personal and professional level. The year started with me in a deep depression triggered by the constant stresses of 2020 and I was struggling to find self-coherence. I was becoming fused to my feared self and there was a discrimination between who I hoped to be and who I was becoming. I had been through depression many times throughout my life, I knew what I had to do to get me out of this hole. I got some counselling, ramped up my mindfulness, went back on antidepressants, started doing things that made me, me and I dropped the struggle with trying to get rid of depression. Depression was there and it wasn’t nice, but I focused on what I could control and over a couple of months I slowly improved, and I started to see the world again in HD and understanding more about me.
In February I enrolled in an online course that was right up my alley, ACT in the clinic with Laura Rathbone, a Specialist Physio from the UK. I was a bit worried going into the workshop that I was maybe not qualified enough, or my knowledge wasn’t in depth enough. This self-doubt had been there throughout my life, but I never realised how much it controlled and influenced me. After the first week of the workshop, I quickly realised that the journey I had been on over the past few decades had put me ahead of the pack, but my self-doubt was still strong. By the end of the course, I had let the group know of my worries, self-doubt and I noticed a few confused looking faces looking back at me in the computer screen. A powerful moment happened at the end of the course for me, when Laura messaged me:
“You clearly have a huge body of knowledge and experience already, I know you mentioned that you weren’t sure if you would be qualified, this was a bit of surprise to me because I sat with worry that I couldn’t add much to your journey!”
This was a powerful moment, as I have a huge respect for Laura. My self-doubt was starting to have less of an influence over me and I was learning to own my space.
At the same time, I was doing the ACT course, I was doing some work on self-doubt and values with a local counsellor Amy. Some powerful words from Amy who I also highly respect were “Mat, it’s time to drop the self-doubt and own the space”. I was again dropping the struggle with another part of me and embracing the person I am, guided by what I value highly care, empathy, relationships, learning and helping others. When people used to give me compliments, I would always deflect it and not own it, now I am embracing it. I found the process of exploring who I am and why I do what I do, to be really stimulating and fascinating, a process I will continue to do throughout my life.
A few months later I was involved in group discussion on ACT run by Laura. I presented a case study for the group to pick apart. This session was another light bulb moment for me, as it showed that I was trying to blend different frameworks like CFT, Explain Pain etc together, instead of looking at the processes at play. A process-based approach was something I had been working towards for many years, but I didn’t know how to define it until this moment.
“Instead of taking a protocol off the shelf and delivering a protocol, everybody comes in with unique problems, lets make sure we identify problems and goals in an individual way” (Professor Lance McCracken)
“What core biopsychosocial processes should be targeted with this client given this goal in this situation and how can they most efficiently be changed?” (Hofmann and Hayes 2018)
Now when I am reflecting on case formulations in the clinic, I am exploring the different processes at play, what is maintaining the predicament? what process can I help to cultivate a change? Which processes can trigger a cascade of change in other processes? Letting go of protocols and really exploring the person and how we can help them.
In June this year, I decided to leave the practice I had been working at for 19 years, I was actually still working in the same room I started the business in all those years ago. One thing for sure, I am a committed and loyal person, that was strongly attached to the building and the amazing people there. But it was time for a change, it had been something I had been working on with the counsellor over the last 6 months, when I realised change was imminent. When the time came in June, I was ready to make the move that would allow Bec, Sally and I to grow. I found a warm inviting space that I will share with Lachlan and Clare at Upwey Chiropractic. Networking with Upwey Chiropractic over the past 6 years, I knew that we shared a lot of the same values. When hiring new clinicians or working with others, having similar values is one of the keys to a strong relationship in a practice and amongst clinicians. While the lockdowns through June, July and August were challenging on many levels, it gave me a chance to fit out the clinic and go back to my tradie roots and clinic looks amazing. In the new space Tecoma Myotherapy will infuse our spirit through the clinic of love, care, respect and a stimulating learning environment, where will grow and help others.
This second half of year I will be doing an intense course with Mick Thacker, who is a giant and legend in the science of pain. We will explore pain from a predictive processing, philosophical and phenomenological perspectives, this will challenge what I think I know about pain and human experience. Being challenged is how I grow, even though at the time I might get defensive, when I reflect on being challenged this is where I grow and learn on this journey of becoming less wrong.
Professor Lance McCraken, LePub Scientific, 2020
Hayes & Hofmann, process based CBT, New Harbinger Publications, 2018
By Mathew Richardson
When I was going through chronic pain 10 years ago, there was a distinct turning point when I turned from someone in chronic pain, to being a person again. In the months before this day, all I could focus on was pain, it consumed me day and night. My life revolved around my pain, how to get rid of it and what it meant for me, my family, my future. When I am low, I tend to ruminate, focusing on the past and future and not in the present moment. I was missing life without being aware of it and the future was dark, if I could see it at all. I wanted to get rid of the pain and I could not control it. I started withdrawing from life to protect myself, I stopped doing the things that made me, me. I stopped exercising, gardening, I stopped playing with my kids, stopped putting my daughter on my shoulders and my mind was always on the pain.
A seed of change was planted a few days before my darkest day with chronic pain, when a family member mentioned that she was struggling with depression and had gone on antidepressants. This was the first day I started acknowledging to myself that I was depressed. Until that point it was all just pain. Two days later I woke up and I remember laying there in bed, thinking if I died at that moment, I would not care. It would have been a relief.
It is amazing how one day can be so influential in shaping your life. On this day, I decided to let pain be, bringing acceptance around it and shifting my focus to my mental health and living life again. I was not aware at the time how important this decision of accepting the pain was, until many years later. In Acceptance and Commitment Therapy (ACT) we would call this creative hopelessness. Creative hopelessness is when you stop trying to control emotions or feelings and putting your energy and attention on what really matters to you.
Creative hopelessness is a name I do not necessarily like, as it gives them impression, we are creating a hopeless future, but the term refers to the hopelessness of trying to control emotions and feelings. Instead, it is a willingness to let them be – dropping the struggle and switching the focus to who you want to be, what you stand for in life.
“Creative hopelessness is a process in which one becomes aware that trying hard to avoid and get rid of unwanted thoughts, emotions or feelings this tends to make life worse than better. The aim is to increase a client’s awareness of the emotional control agenda and the costs of excessive experiential avoidance; to consciously recognise and acknowledge that clinging tightly to this agenda is unworkable” (Harris, 2019)
I do not count the pain experience from 10 years ago as being a negative experience. It triggered a cascade of learning and defines a lot of what I do today in the clinic. This experience allows me to build stronger relationships with people with persistent pain. I help them on their journey to a better and more full life, despite their pain. I won’t rush in and explain creative hopelessness with people; I build a relationship and slowly plant seeds with language around willingness and acceptance. When it is appropriate I bring up letting pain be, dropping the struggle to focus on their values and making life bigger despite pain.
A finger trap is one way I explain creative hopelessness to people. (I don’t always use the finger trap as I adapt for every person.) I give the person a finger trap, and they look at me questioningly. I incorporate the person’s story into the finger trap exercise like so.
This script I run through, but remember, this is a guided discovery so give the person time to think:
Person in pain: They look at it with curiosity.
Mat: “Place your fingers in the trap and try and get out of the trap”. Most people will try and pull their fingers out of the trap, and they get more stuck. “Imagine this is you with pain. You have been fighting it and trying to get rid of it for years. Most therapies you have tried give you short term relief, but how does it work in the long term?”
(Get person to reflect)
Person in pain: Usually, the reply is not well.
Mat: You have stopped doing what you love (reflect on the costs of experiential avoidance). While we are focused on getting rid of pain, your life is on hold. Are you willing to try something different?
Person in pain: Hopefully, the person will say “yes”.
Mat: “Is there another way you can get out of finger trap?”
Allow your fingers to gently come together and give yourself a bit of space. We can find some wriggle room to get out of the trap. (Reflect on this). Stopping the struggle with the pain and bringing a focus on what make your life bigger will move you towards the person you want to be (include what the person values).
Deciding to move forward in spite of their pain involves “…comparing their ideographic model of pain with both the cost of pursuing a “return to normal” and the rewards from engaging in what is essential to their self-concept” (Thompson 2019)
My personal experience of creative hopelessness was a powerful moment in my life, even though at the time I did not realise it. Focusing on what is important to me and dropping the struggle with emotions and feelings enabled me to put my energy into living life again. The skills I learnt through mindfulness in the months to come after this time, were some of the most rewarding and challenging skills that I have learnt in my life. If you are practitioner, what you say and do in the clinic may help or hinder the person in pain from moving forward on a journey of living well with pain. Consider how you may apply creative hopelessness principles to bring your client’s focus back to life.
Harris, ACT Made Simple, New Harbinger Publications, 2019
Thompson, Gage, Kirk, Living well with chronic pain: a classical grounded theory, Disability and rehabilitation 2019
The idea for the finger trap came from a workshop with Bronnie Lennox Thompson and Alison sim in 2019.
By Mat Richardson
My Journey with ACT started 10 years ago when I was suffering with chronic pain (A link to a blog on my pain and depression), I was lost and couldn’t see a way out. I used a similar framework to ACT to get me out of trouble and didn’t even know this is what I was doing. My shoulder pain had been present for over a year and I went down the traditional biomedical pathway of diagnosis, treatment & resolution of pain. If you can’t enter this pathway, or you do and don’t get resolution, what then? For me I spiraled into depression and pain and was becoming fused to my undesired self. Adopting experiential avoidance as a coping strategy, I started participating and engaging in less activities. I was losing flexibility in life, had no clarity on my values or who I was and all I could see was the sick and undesired self. At this time, I was very fused to my thoughts and feelings, my mental health and pain spiraled downward.
Then the turning point: one day I woke up and thought if I died at that moment, I wouldn’t have cared. I picked up the phone and called my doctor to get help for my depression, she put me on antidepressants and at this time one of my patients introduced me to mindfulness. Both ingredients were key for me getting out of my hole. Mindfulness taught me self-compassion, that thoughts were not fact and that I could create space and not automatically respond. I became less reactive and more reflective, I was able to sit with sensations and feelings without reacting and bring a curious mind to them and stopped the struggle with them. If someone had used the word acceptance back then I might have punched them, but using a willingness to let pain be and focus on what you value, was more acceptable to me. I looked at my life and started clarifying what I valued, what made Mat, Mat. Gradually I started to see who I really was and started to get flexibility in life. Over a few months the pain went away, and my mental health improved. Without realizing it I had done an ACT intervention on my self, but I didn’t know what ACT was until many years later.
ACT aims to increase Psychological Flexibility, “to maximise human potential for a rich and meaningful life, while effectively handling the pain the inevitabley goes with it” (Harris, 2019). Psychological flexibility has 6 core processes with 4 of them directly from Mindfulness.
- Contact with the present moment
- Self As Context
- Committed Action
The first part of my story I was doing the opposite of ACT, I was becoming psychologically inflexible. I was caught in a trap of trying to get rid of pain and couldn’t live life until it was gone: trying to find the silver bullet and my life was on hold (Bunzil B. W., 2013). I had become psychologically inflexible- not connecting with the present moment, remoteness from values, unworkable action, fusion with undesired self and experiential avoidance (Harris, 2019).
A little exercise if you are a Practitioner: what components of psychological inflexibility may relate to the Yellow flags, that predict a patient with a poor outcome and may lead to pain related disability?
2 years ago when I attended a workshop run by Alison Sim and Dr Bronnie Lennox Thompson exploring how ACT can be used to help people with persistent pain and I realized this is essentially what I did many years before. The processes involved with ACT tickled my biases, as I had already been practicing Mindfulness for many years. ACT is a third wave Psychological therapy that was developed mid 80’s by Steven Hayes. Now I am not saying for manual therapists to become Psychologists, but what I am saying is there are trains of thought, processes and techniques we could use in the clinic that could be very helpful when working with people in chronic pain. We are not digging into trauma or diagnosing psychological conditions as this is outside of a lot of our scope of practice. I believe we need to know about these different approaches so we can work with counsellors or Psychologist to give the patient consistent messages, hence having a wide referral network is invaluable.
The best person to practice ACT on, is yourself, so during the second wave of Covid 19 and stage four lockdown, I drew up a choice point, I could see all the triggers for my stress and anxiety were present: I couldn’t work, money getting tight, home schooling kids and uncertainty with what will happen next. On the bottom I placed the situation: stage 4 lockdown where I was unable to work, high stress and anxiety. I then drew 2 arrows one towards the person I want to be and one away from the person I wanted to be, guided by my values. I did some work with values clarifications and wrote them on the top. Functional contextualism is a key idea that flows through ACT, where a behavior is neither good or bad. Rather, “what effect does this behavior have in a particular context”(Harris, 2019) and whether it moves you towards (workable) or away (unworkable) to the person you want to be (values). You will notice drinking alcohol appears on both sides of the arrows. When I am not stressed, two or three beers tends to relax me (towards), but if I am anxious or stressed, two or three beers can amplify these responses and can affect the quality of my sleep (away). With watching the news I needed to watch enough to know what was going on (towards), but not checking in all the time or watching the news throughout the day because this would trigger my stress and anxiety (away). Mindfulness appears strongly in my “towards me” arrow, as it allows me to defuse from the stressors. This allows me to make space for them and not attempt to push them away (acceptance). I filled my day with lots of towards moves but there were still days where I was down or frustrated and this is alright!! I just didn’t allow myself to get caught up in the struggle, and brought acceptance to them and controlled what I could control.
Image- Adaption of the choice point (Russ Harris)
ACT has a large clinical framework, full of process and tools to use. I haven’t gone into depth in this section of the blog, as I only wanted to get across the essence of ACT and tickle your curiosity to explore further. One aspect of ACT I love is: you are 2 humans that have experiences, share and work collaboratively together to get you out of a predicament whilst building more skills and coping strategies for the future. You can choose workable actions towards the person you want to be and build in a range of coping strategies for the future. I need to be watchful as personal experience has given me a huge confirmation bias towards these types of therapies and interventions and need to keep checking in on myself.
Harris. (2019). ACT made simple second edition. New Harbinger Publications.
For a full reference list see blog on Pain, Protective Responses and Relationships