Powerful Words

It felt like he came back to shake my hand 5 or 6 times. Big smile. Effusive praise. He was clearly delighted. He was back on his bike. Confident about his future. Which was a big turn around from 8 weeks earlier. A young man (mid 30’s- I say young as same age bracket as me). He felt “his life was over”. He had been “getting worse and worse”. I’ll always remember him by his thick Kiwi accent. The subjective had gone longer than expected. He’d had episodic LBP for a long time. This episode after a long car journey. But it was taking less and less each time. He was now “conscious of his back all the time”. Even when it wasn’t hurting. This was interesting I thought. Should we be conscious of a body part even when it’s not hurting? I delved further to his history. Oh yeah and he’d had a lumbar fusion. Thought you’d pop that one in there last minute did you? Aged 19 a rugby injury lead to a spinal fracture. The surgeons decided to stabilise/fixate. This may have been the best treatment for him at that point. However what came next was the key to his case. “So what did the surgeon say after the op?”

“Well he said I needed to be careful, take it steady, that it was pretty severe, in fact he said if he’d known how severe it was he would have used a stronger fixation device!”

“He said WHAT?!?!”

“The physio then advised on lots of bracing techniques, log rolling in/out of bed, lots of core stability, but now every time I bend it hurts”

“So you’ve basically avoided bending for a lot of years and now when you have to it hurts? Is that a surprise to you?”

If we are taking a history we need the narrative. Otherwise we are taking a questionnaire. Skimming data from detail. One of the first stones to be turned is previous healthcare experience. Have they been referred by another practitioner? Have they consulted anyone else? Usually for me it is a GP referral. So I ask them when they saw the GP “what did she say?” Trying to get it in their words. Rather than from the referral. Discrepancies are frequent.

Sticks and stones may brake bones but words will never harm me. This is true. This is false. It is a polemic for dissociating with harmful words. Words cannot directly cause physical harm. But words are powerful. The context they operate in help to load or unload this power (Naked physio blog illustrates this nicely). The surgeons words here hung heavy. But heavy as they lay equally they can powerfully free. If there is power in words we need to know what they are. Allowing people to use their own spontaneous language rather than words or numbers prepared by us. The poster below (from Gurpreet Singh) is an excellent example of qualitative research uncovering powerful words specific to people and cultures.

People in pain often face an existential crisis. Their existence becomes afflicted. Usurped. Consumed. Their world is hi-jacked. Their words insight into their turmoil. Words spoken require understanding. Words heard need to fit.

So what makes words powerful or meaningful? We can search ourselves for clues here. What are the words we remember. That stick with us. What are their characteristics? Are powerful words likely to be specific or generic? For a person or population? If we get an email/tweet/message are we more likely to respond if generic and to a group or if it is personal, specific to us and engaging. Obviously other contextual factors matter here. There is no absolute. As therapists are we repeating words we feel we should, or we have read, seen or that matter to us, or have worked before. Or are we trying to speak to the individual in front of us. Of course some of these things may be applicable. Sometimes I wonder if I recited information and advice hoping that something will connect. Now I wonder if this is why connection didn’t happen much!

So how do we make this connection? Well something I have been doing lately is recording verbatim. Not every word. But those about feelings, description of pain, possible maladaptive beliefs or behaviours. Anything that prods my conscious. I usually use a separate blank sheet for these quotes as often they come at inopportune moments. Like when the subjective is ‘done’ (fallacy). From a physiotherapy perspective how well do our SOAP notes (subjective, objective, assessment, plan) allow this? You may notice the quotation marks in the above case study. These were the elements I earmarked in this case. Then our job is about redemption. How can we free people from these. Robotic redemption is something I’ve yet to see.

Redefining Old by Dustin Jones
In this case some reassurance and a graded reverse deadlift were the “only” intervention required. In much the same way I tell my son the best way to get it better is to use it. Those redefining ground include Dustin Jones (+ others, see above image) who are reshaping our approach to older populations, and Peter O’Sullivan, Helen Slater, Mary O’Keefe, Derek Griffin and Kieran O’Sullivan who are writing to powerfully change how people view back pain (see here and here).

Are we skimming data from detail?
Are we asking what their GP/surgeon/physio said to them?
What will they say to your family? (The Kieran O’Sullivan Test)
What’s the thing they remember most about physiotherapy? Important questions if you are patients are human!

Be more human. Be less robot.

Thanks for getting this far.

Neil

Further reading

Probably my favourite blog of the year from Jo Belton exploring language and meaning (http://www.mycuppajo.com/meaning/)
Todd Hargrove’s blog discusses unintended consequence of language http://www.bettermovement.org/blog/2015/three-reasons-it-matters-why-a-treatment-works

Content

Lagerman (2015) http://www.thenakedphysio.com/?p=1866

Jones (2015) Redefining Old http://www.seniorrehabproject.com/products.html

O’Sullivan + Slater (2015) http://bit.ly/whatisLBP

O’Keefe, Griffin + O’Sullivan (2015) http://bit.ly/LBPeire

11 thoughts on “Powerful Words”

  1. Afternoon Neil,

    The subjective or c/o is never over is it? My notes seem ever more full of ‘during P/E patient said….’
    We have to talk in the native tongue of the person I think.
    People take what health care workers say to them seriously as a rule and literally. You are right that we have to take what people say to us responsibly and carefully think what we are going to say back. There is nothing wrong in saying ‘ what I just said to you is not what I meant…..’.
    Dispelling firmly held beliefs needs tact in order to avoid the person feeling like a fool. On the other hand, most people look relieved when the beliefs they hold are negated with simple, logical thoughts delivered in a non patronising manner. I often wonder if people force themselves to believe what is said just because of authority.
    Should we just ask people what they honestly think about their own issues along with their thoughts on what other people have said to them.
    We are sometimes guilty in our profession trying to objectivise the non objective. SOAP notes make me laugh. I doubt there has ever been a truly objective event written under the O heading.

    Kind regards,

    Adrian

    Liked by 1 person

    1. i agree native tongue is important both for patient understanding, but also to stop us from being enveloped into a professional process of assessment distancing us from the patient and not allowing them time and space to help us understand what they want, how they feel etc.

      I often find myself using phrases like “well what do you mean by that” “can you describe how you feel/think about that”. Often I have skipped over this and pretended to understand for simplicity, time etc it requires time and conversation to truly understand. And more than 1 layer of conversation too!

      Thanks always for your insightful comments they always help me to process!

      Like

  2. Another lovely post Neil. Thanks for the mention. On 1 hand i think we will make v little progress in clinic without changing overall societal beliefs regarding msk pain. Smoking rates have not declined due to 1:1 clinic based ‘chats’! which is why i have done a few mass media type things. However the mass media stuff misses the detail you mention above. As it will never cover all eventualities. And it is provided (especially paper/text based media) with less opportunity to develop a rapport. So a much higher chance of backfire effect. so think we will always need clinician to translate science into a narrative that gives personal meaning to person. And hopefully patient is prepared for this by altered societal beliefs.
    Finally, worth looking at the social media comments on our 15 things piece. Those already ‘converted’loved it. But the real target audience (those whose beliefs were not in line with evidence) mostly HATED it. Esp on Facebook. Not a shock, but reinforces idea that the medium/manner through which information is provided matters a lot.

    Keep up the good work

    Liked by 1 person

    1. Thanks Kieran! Great insight.

      I can see what your saying. The difficulty is like I mentioned in the blog is that the words have to fit their experience. If they have a pre-existing narrative I think mass media will struggle to connect unless it directly speaks to them. The situations I can think of are when people are google searching and find symptoms that explain them. Yours + Peters pieces that I allude to are excellent content and seem to be accessible and easy to understand but maybe so comprehensive that it’s difficult to connect with it all. I think (total anecdote!) that I make more connection now by trying to provide specific information on topics that seem to be important to the person or like I mentioned using direct quotes to help them feel understood. Rather than a plethora of information and hoping some sticks! It’s a predicament to be sure.

      Once again thanks for taking the time to read and reply!

      Neil

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      1. Agree that specific personalized info seems more ‘sticky’. The generic media stuff probably serves best to reassure patient that you are not alone in saying this!

        Liked by 1 person

  3. Neil, how did I just now come across this? Fantastic, both the original post and the comments. I wish I had read this before my last post because I would have added that language is weird and complicated, too. So humans + language + pain = a big, huge, weird, complicated mess. A wonderful, fantastic, awesome mess, but a mess none-the-less. Layers upon layers upon layers.

    Language is so important, and I commend you for taking the words your patients use so seriously and use that to inform your clinical decision making and steps forward with them. And that you are so careful with your own language. I love the ‘What are they going to tell their family” test and need to use that more frequently.

    As I experienced when my mom was diagnosed with cancer, most of what the doctor said to her was incomprehensible in that she couldn’t convey any of it to me, other than ‘cancer’. What most patients hear is blah blah blah SCARY WORD blah blah blah SCARY WORD blah blah blah SCARY WORD blah blah blah 2 TIMES A WEEK. It doesn’t matter what came before or after the scary word (it could be “you don’t have to worry about…’), all that sticks is those certain words that they were afraid of going in, if that makes sense.

    And I imagine it’s hard to get at what patient’s are really thinking, about what they would tell their families. It feels like a test and people don’t want to fail. They don’t want to say the wrong thing so they say what they think might be the right thing, even if it’s not their own thoughts or words. No one wants to appear weak or unknowledgeable, so we fake it (on both sides of the table).

    Anyway, I could go on for days about words, as you know (I never to seem to be at a loss for them!). I am so happy I know about your blog now.

    Thank you for all of your kind words and support of my own words. I look forward to reading more of yours!

    Liked by 1 person

    1. Thanks for your feedback Jo.

      Great comments. I love how you see words and how they affect us. Part of a therapists job is to form a therapeutic alliance, which means getting beyond the fake and fostering something real. Which often means being vulnerable and not the answer to every problem.

      Liked by 1 person

  4. When you say something… “the client becomes aware.” Conversely, when you describe something to the client… “the experience becomes real.” We work with words — but it’s not the words that cause the subconscious mind to surrender control and just go ahead and change. In fact, you don’t even have to remember… “it’s the chaining of affect/effect to get the client moving from one state (mind-set) to another.” Hypnotically, this is one of the core ‘secrets’ to being a highly effective trainer.

    Liked by 1 person

    1. It is interesting how we don’t remember the vast majority of words spoken to us. Just the underlying meaning (that we took on board). There are occasions where I can remember exact words and these are more affective, but the tone, context etc are often as important. As is the experience of something good.

      Like

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