Welcome back to the Healing Pain Podcast with Davide Lanfranco, PT, MCSP
We’re discussing how to target pain catastrophizing by using a core process of acceptance and commitment therapy called cognitive diffusion. My expert guest is physiotherapist Davide Lanfranco. Davide is an Italian physiotherapist who works in London. He is a member of the Chartered Society of Physiotherapy and is one of the Founders of FisioScience International, an online platform which aims to spread evidence-based knowledge about pain. In this episode, you’ll learn how pain catastrophizing impacts both physical and mental wellbeing, all about the cognitive change process of cognitive fusion, how it’s different from other cognitive interventions and how we can teach patients unhook from unpleasant or unwanted thoughts about pain.
Cognitive fusion is a time-tested, science-backed approach that has helped thousands of people experiencing chronic pain, as well as those suffering from stress, depression, anxiety, trauma, and addiction. Cognitive fusion is a key part of my latest book, Radical Relief, which is rooted in the principles of acceptance and commitment therapy. Radical Relief, which is written for both practitioners and for people living with pain uses metaphors, colorful imagery and includes more than 40 mindfulness activities to help you identify the blocks that may be keeping you stuck and offers tools for taking meaningful action toward a more fulfilling life. It’s available on Amazon and in most countries. Let’s begin and let’s learn about cognitive fusion techniques and how it can help pain catastrophizing with physiotherapists Davide Lanfranco.
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How to Apply Cognitive Defusion Techniques To Target Pain Catastrophizing In Physiotherapy Practice With Davide Lanfranco, PT, MCSP
Davide, welcome. It’s great to have you here.
Thanks for having me.
I know you’ve done some great work in the world of physical therapy or physiotherapy as it’s known on your side of the world, and especially with regard to psychologically informed physical therapy or psychologically informed physiotherapy. We’re going to talk about pain catastrophizing, why it’s important, why people should learn more about it, and how we can target it with different types of techniques. One particular, which is called cognitive fusion. A good place to start is to explain to people what pain catastrophizing is so they can understand it in simple terms.
Pain catastrophizing is not a nice term. I apologize with the least scenario theories any of you experiencing persistent pain because pain catastrophizing, at least at me gives me the idea of someone that is almost overdramatic. We know that people experiencing persistent pain are not overdramatic, that’s not the problem. I would use pain catastrophizing here because I don’t have a better term to describe it. We can say that pain catastrophizing can be described as an exaggerated, negative orientation towards an actual or an anticipated pain experience. Pain catastrophizing is not there only when pain is present. People can have the features of pain catastrophizing, even when we are pain-free in anticipation for a possible future experience.
Let’s talk about the story of the history of its term, probably the first good paper that describes pain catastrophizing and brings to the attention of the scientific word validated scale to describe it is the paper of 1995 of the health psychologist, Sullivan. In this paper, Sullivan, apart from presenting the pain catastrophizing scale, but is still widely used and is a quick and effective tool as an idea of a much pain catastrophizing is going on. He describes what pain catastrophizing is, and he describes it as characterized by three different features. In the paper, he says the three characteristics of pain catastrophizing are rumination, magnification and helplessness.
Let’s have a look at what they are, what they mean and what they look like. Rumination is not a term that has been created by Sullivan because he seems the first one to use it that was a few years before. Rumination is a term that has been much associated with problems like depression or anxiety. Only lately has been introduced in the realm of pain. Rumination can be described as that worry and inability to inhibit the pain-related thoughts. It can be described as a pattern of pervasively thinking about once emotional symptoms, or for example about the pain in this case, but as well as the causes and the consequences of his symptoms. Rumination is not only about the experience why the pain itself, it’s about thinking about what may have caused it and what may happen in the future, what could be the potential consequences of that.
Rumination also is a person that can tell you, “I cannot stop thinking about my pain.” That brings me to the memory patient that was discharged. When she came for the initial appointment, this lady who has been experiencing lower back pain for many years told me when I asked her, “How can I help you?” She said, “When I wake up in the morning, I think about my back. When I get out of bed and go have breakfast, I keep thinking about my situation. As I eat breakfast, I cannot stop thinking about what is going on, and as the days goes on, when I’m in the meeting, when I’m at work, when I’m shopping, I keep thinking about my pain. The only moment when I don’t think about my pain is where I’m in engaged in an interesting conversation. At that moment I can add a little bit of freedom from those thoughts.”
That is a description of how rumination can show up. There is an overwhelming amount of evidence in the literature describing a strong association between rumination, anxiety and depression. People who tend to ruminate a lot tends to potentially sink into depression. It’s an important factor that has to be addressed. The other one is magnification. It relates to an exaggeration of the experience. This can be a bit tricky because we always commit the scene of judging someone else’s experience. We tell them, “You shouldn’t be in so much pain. You shouldn’t be feeling these according to what I know.” We run the risk if you’re careful of invalidating the person’s experience. Magnification relates to a big exaggeration of the experience. For example, thoughts are like, “This pain will never get better. There’s nothing that can be done to help me.” These sources of magnification.
The third feature that described the pain catastrophizing is helplessness. Helplessness is quite self-explanatory. It relates to the perceived inability of dealing with the situation. Thoughts like, “I cannot get on top of this. I will never get better. No one can help me.” Pain catastrophizing is something that does not occur only on people with persistent pain or people with being in pain for many years. Pain catastrophizing can happen to any person, even if their pain is more acute or subacute. It’s that type of people that we have to be even more careful and more ready to target. I encourage people to read the paper of 1995 on pain catastrophizing. Even if it’s several years old, it’s still fresh, actual and interesting to read.
It’s a great introduction to our episode because pain catastrophizing is been around for a long time, and at many decades grew out of the traditional cognitive-behavioral literature around ruminating thoughts with regard to anxiety and depression. Someone studied it and translated some of that research and evidence over into chronic pain with regard to pain catastrophizing. The way you started off Davide is the most important thing you’ll say the entire episode in the sense that word’s been around for a long time. It’s used in popular culture and pop psychology, but it’s confusing to someone with chronic pain, in a way it sounds like we’re telling them that their thoughts are maladaptive, aren’t good, bad, or however you want to frame it. Catastrophizing exists in everyone in many different shades and it also exists in people without pain.
I’m catastrophizing. I keep thinking, “Will I say clever things? Will the people like it if everything goes south?” Part of being human is our mind trying to do its job to keep us safe. Sometimes it gets over-protective.
It’s a normal mode of the mind with regard to worrying about things in the future or planning with regard to things in the future. How important is it for clinicians to normalize this pattern of thinking for people living with chronic pain?
It’s important. It’s crucial both in people who experience more of an acute condition, and it’s crucial as well for people to experience more of a persistent condition. There is an overwhelming amount of literature telling us pain catastrophizing is a predictor of chronic symptoms. We know that people that are in a more acute subacute phase with a high level of pain catastrophizing so their score’s high at the pain catastrophizing scale, for example, has a higher likelihood, possibility or chances to develop chronicity. We know that in low back pain, 20% of the people that develop low back pain will end up having a persistent problem. Still, even if the real mechanism is not clearly fully understood, we know that pain catastrophizing is a strong predictor of these chronic symptoms.
In people instead that are already chronic or experienced already longstanding conditions, those catastrophizing thoughts are a key factor that contributes to maintain the chronic pain and the disability. The fact that the person engaged in such catastrophizing anxious thoughts is more likely to have a higher level of disability and that maintains the condition. Pain catastrophizing predicts, not only with things but predicts actual pain intensity and psychological distress as well. People with a higher level of pain catastrophizing are more likely to develop anxiety, depression and a higher level of pain. I read the paper that was published on pain and came out fresh from the printer. It’s published in November 2020 on pain catastrophizing. It predicts less physical activity in all adults with knee osteoarthritis.
What they did in this paper, they recruited 143 older adults with knee osteoarthritis and they ask them to complete electronic daily diaries for the period of 22 days, at the same time to wear an accelerometer in order to capture their physical activity and sedentary behavior. They ask them at the beginning of each day to report their level of pain catastrophizing regarding the day to come. They demonstrated that when the patients were catastrophizing more than usual about their pain in the head, they spend more time in sedentary behavior and engage in fewer means of physical activity. That food space in the morning were a predictor of how much physical activity they were doing during the day, but the other side is that the more time they spend in sedentary behavior, the less physical activity they did, the more it contributed to a greater pain catastrophizing in the next morning. It’s a vicious cycle. More pain catastrophizing, less activity, more pain catastrophizing as a result of even less activity.
They found another connection between pain catastrophizing and avoidance of physical activity in this case, in people with osteoarthritis, but it stands to reason that it relates to a great deal about their condition. The conclusion was, if you address pain catastrophizing, you also reduce sedentary behavior. Addressing pain catastrophizing is crucial and understanding that the person is having catastrophic thoughts in the early days when they come into the clinic is important. It’s something that has to be addressed more.
Two interesting important points that you mentioned there, the first is your last point there that pain catastrophizing leads to less physical activity. As a rehabilitation professional, a physical therapist, a physiotherapist, that’s important. Not only can we target pain catastrophizing from the cognitive perspective, but helping someone engage in physical activity in essence using the body to affect the mind is a way to impact pain catastrophizing. The other important point is that often we think about pain catastrophizing with regard to chronic pain. You mentioned that the most important place we could help people target catastrophizing is in the acute phase of pain so it doesn’t turn into the chronification so acute pain doesn’t turn into chronic pain that lasts longer than that 3 to 6 month period of time. What I find interesting about that is, as physiotherapists, we’ve been so focused on pain education which is important and has its place. Pain education hasn’t showed us that it’s necessarily effective in the acute phases of people with pain.
There are some studies showing that neuroscience education compared to perceived education have similar results. I still think that providing the patients with the basic information regarding their experience to help them make a sense of their experience, it’s important and can be crucial in their recovery. At the same time, we need to target their cognition and the way they relate to the problem, and addressing in the early stages their faults and the type of faults they have and how they relate to those faults. It can be crucial for the recovery ahead.
As a physiotherapist, I know you’ve used a number of interventions, pain neuroscience education, or pain education, cognitive behavioral therapy, acceptance and commitment therapy. In your mind when you approach these different methods and you think about patients, what’s the difference you see between ACT, CBT and pain education?
There are significant differences in the way they approach the problem in which we approach cognition. The big difference is that pain neuroscience education is more into a reconceptualization of the experience. It’s helping the person understanding that the pain they’re experiencing is not because they have herniated disc, but it’s because of other factors and the pain experience is much more complex. The more traditional cognitive restructuring that belongs to the traditional cognitive behavioral therapy, instead is more into challenge the thoughts, to change the thoughts, to replace the thoughts, to change the way the person thinks about their experience bringing evidence.
Someone says, “I’m worthless, I’m beyond help.” You may say, “No. This evidence is not right.” Helping the patients to see the situation from another perspective, to replace the thought or to suppress the thoughts as well. What acceptance and commitment therapy do instead, we don’t care much about the content of the thought, the veridicity of the thought, or the type of belief the person has. We care about how the person is relating to that thought, how much that thought is impacting on their cognition, and how we can act in a flexible way in order not to be impacted by that thought in a nutshell.
You mentioned beliefs there, which pain-related beliefs come up in the literature, pain-related beliefs come up in many different types of pain education interventions, and it can be difficult for someone who first comes to a mindfulness and acceptance approach. There are many different types of them out there, but act as ACT is one of them. It’s difficult for practitioners to think, “I have to change someone’s belief about pain,” versus having someone relate differently to their belief. It’s difficult because sometimes when you’re trained a certain way, it’s hard for them to be flexible, shift gears, and realize, “Maybe I don’t have to change someone’s belief, or maybe that belief will never change, but I have to help them relate to that belief or allow that belief to be present as they do other types of activities in their life.”
It’s crucial and important. As physiotherapists, sometimes we do big damages in the relationship with the patients when we try to convince them at every cost that they are wrong and we are right. Some words from a colleague of mine named Paolo Marighetto, when he teach his courses, there is always a sliding which is trying to convince the patient that they are wrong and we are right, or their experience is not the way they think it is, it’s like trying to convince the Pope to become Muslim. You can give it a go, but good luck with that. If someone comes to me and there’s a twenty years long belief that there something growing in the back, I can try to refrain to reconceptualize that belief once or twice, but that’s it. Otherwise, I would lose ruin the relationship with the patient. It’s ACT that teaches us how to make sure that the belief can stay there, we show you how to make it impact lesson your life. We have to stop the tendency views, this attitude of trying to change people believe, in general, is not right.
You said something important. I interviewed a pain researcher and psychologist from where you are in England. She’s run a number of meta-analyses and systematic reviews on traditional cognitive behavioral therapy for chronic pain. In her last review, she mentioned that we don’t have a whole lot of information on whether or not traditional cognitive behavioral therapy can be causing some harm for people. Any intervention at all can do good, it can be neutral and have no effect, or it can cause harm. One of my main concerns that I’ve always talked to therapists about with regards to beliefs and pain is that if you’re so attached to that belief and you’re driving home that belief to a patient. That belief isn’t changing and they’re not changing, and you’re not aware that they’re unable to change, or they’re not at the phase yet where people will change.
Sometimes it takes people years to change our beliefs about things. You mentioned damage. You may be doing harm for someone where if you take a more mindful and acceptance approach, you can navigate around that belief in a way that’s, one, healthier for the patient. Two, healthier for you too, as a clinician. If you’re going to work every day trying to change beliefs about pain, some people have had pain for decades and those beliefs we know from good research don’t change so frequently. That leads to a tremendous amount of frustration and burnout in practitioners, especially pain practitioners where frustration or burnout is high already.
It’s a form of self-protection and self-care as well. Human beings are not convinced by facts and objective truth. It would be easy otherwise to do our job, but if we could show you not, these are the evidence, “Thank you. I will follow them.” We sometimes don’t see the objective truth in front of us. It’s simply seeing someone the way you think is longer, it won’t do much.
What may seem logical to us as licensed healthcare practitioners based on facts is not so logical to people living with pain that facts don’t necessarily change behavior. That brings us to cognitive fusion, which is a method in acceptance and commitment therapy. Tell us a process, and ACT as well as the method what cognitive defusion is.
Cognitive defusion is 1 of the 6 aspect core elements that contribute to creating psychological flexibility. Acceptance commitment therapy is one of the aims of psychological flexibility in people. Psychological flexibility is defined by cognitive diffusion, acceptance, present moment awareness, values, committed action and self as a context. Cognitive defusion is one of the six phases of that. Before saying what cognitive defusion is, we should say what cognitive fusion is. It’s exactly the opposite. Cognitive fusion is, when a client is relatively fused with their problematic thoughts when they are immersed in the content of what they’re saying without even being able to recognize that circumstances could be other than overviewing them. A fully fused client or someone who’s fused with their thoughts it’s not even able to recognize that they are having thoughts. They replace. They think that the thoughts they are having are true.
To a point in which they don’t even realize there are thoughts passing through their mind and they’re buying so much into that they feel real. The problem with this anxious thought is not in the content itself. That’s why we don’t have to change the context to have a better outcome. The problem with anxious thoughts is that they feel real to the person. They feel threatening, dangerous and real. Cognitive fusion is buying into those thoughts, dwelling upon those thoughts so they become the filters through which we see the world, the glasses through which we see the world.
A person with a high level of cognitive fusion often use terms like, have to, can’t, must, must not, and shouldn’t. Rigid absolute terms. Cognitive defusion is the exact opposite. Cognitive defusion is about helping the person to take a step back from those thoughts. We don’t try to change the content of the thought. We don’t try to convince them of other things. Teach from out to take a step back so the thoughts are not in front of their eyes anymore, stopping them from doing things from having the freedom to choose what they want to do. We teach them how to take a step back so the thoughts are further away from them and they can engage with life.
We are not asking and not kicking the thoughts away. We are giving you a bit of space, so in that space, you can take actions that bring into the direction you want to go. Cognitive defusion is an interesting part of ACT that is completely different from the previous traditional cognitive behavioral therapy, different from pain neuroscience education and has a lot of similarities to mindfulness. If you have practiced mindfulness or you’re familiar with this tradition as well, you may know about watching your thoughts from the distance, seeing your thoughts passing by, not get entangled with them or hooked up with them. For acceptance commitment therapy, the problem is not on the content of the thought, what your mind is telling you and what goes on inside your head. It’s how you relate to them. Cognitive diffusion is about changing this relationship.
Davide put his hands over his face with regard to cognitive fusion, meaning the thoughts are so close to you that you can’t see through them. As if you’re looking at life through a cloudy lens. From that view, the only thing you can see are those thoughts in front of your eyes. As you started to move your hands down away from your face, you gain some distance from those thoughts or those thoughts have less of an impact on your behavior instead of changing the thoughts with a traditional cognitive behavioral therapy. That is what Davide and I were discussing, the difference between acceptance and mindfulness approach to thoughts versus traditional cognitive behavior therapy. If you’ve studied traditional mindfulness or the traditional mindfulness research, there’s a word called decentering, which is similar to cognitive fusion. They’re pretty much exactly the same thing, different researchers have different words and different definitions for how we can use the mind to help people with the thoughts that they’re confronted with. Have you found that cognitive fusion is beneficial for helping people with pain catastrophizing in your practice, Davide?
It has been helpful. I wanted to spend a couple of more words on why cognitive defusion can offer benefits that other types of cognitive restructuring or other methods of dealing with thought offer. I found an interesting paper in the European Journal of Pain that states pain-related thought suppression is one of the most common responses in athletes that are experiencing pain. That leads to more severe and recurring depressive symptoms and is linked to suicide attempts. Thought suppression is about anything but allowing the thought to be there. Distracting yourself, watching movies, putting the music on, trying to think positively that belongs to these toxic messages that are delivered by the society. Think positive, positive thoughts, positive vibes, put away everything that is scary negative, and is not nice and just replace and change it with positive stuff. These toxic messages lead us to the understanding that negative thoughts, scary thoughts or anxious thoughts are wrong, and that must be pushed away. When you push them away, you get their own equal effect. They come back even stronger. Research has shown us that suppressed thoughts are characterized by an increase in the return of the suppress content, and you may be familiar with them in polar bear experiment. I don’t remember in which we show people a polar bear, they told them to try to not think about the polar bear, and it was impossible.
When we tell our patients, and it’s something I hear often from my colleagues they are saying to the patients, “Try to be positive, things will be all right. Don’t think too much about it. Don’t stress too much. Thank you.” If she or he could have done it, they would have done it already. You don’t need to tell the person, “Think positive. Don’t stress about it. Don’t worry.” Acceptance and commitment therapy and cognitive defusion teaches us how to do this from another perspective and how to take a step back. Cognitive defusion is something powerful, but people with the eye level of cognitive fusion don’t even recognize they’re having thoughts in the first instance. That is the truth. “I have a bad back, that is the truth. It’s not even a thought that is passing through my mind.” They think that it is the truth.
Before going and using fancy and nice techniques that acceptance commitment therapy offers, the first step with these patients is helping them being more aware of their cognition. I would make another example with a patient I had. She came and she said that she was experiencing tremendous low back pain with bilateral, like pins and needles. That was present mostly when she was standing. She was an avid surfer. Surfing was becoming a big problem for her, and the other big problem was in cooking. She couldn’t stand more than 20, 30 minutes, if she stood more than that, she had to lie down one hour to recover. She’s a single mother with two children and every time she went home and cook, after 20, 25 minutes of cooking, she was knackered, and she had to lie down.
She couldn’t even have dinner with the kids because she had to recover from preparing the dinner, and that went on and on for months. She told me as she approaches to cook, the background pain was around 2 out of 10 on a VAS scale. After 20, 25 minutes, it shoots up immediately to 9 out of 10. She was not aware of what was happening in between. She was not aware of the thoughts that are showing up in her mind. We did basic exercise, and we did some exercises to become more aware of what her mind was telling her. When I asked her to notice what was going on in her head, the thoughts were like, “Here we go again. Even this night I won’t be able to have dinner with my children. Which kind of mother I am?”
It was a lot of shame and embarrassment in the role of mother because she couldn’t even provide for the children and all those thoughts are turbinating in her head without her even being aware of them that led to a huge pain experience. By simply allowing her to become aware of them, it helps to decrease the level of pain. First of all, if you want to fight someone, you need to see their face, you need to know who is better at fighting, even if fighting is not the right metaphor in this case, but being aware of your own cognition, what you’re psyching is throwing at you, and your own faults.
If I can spend a few more minutes, how can you do that? We have a simple meditation exercise. You can ask your client to close their eyes and do 30 seconds, 1, 2 minutes meditation. Ask them to put focus on their breathing and tell them, “Sooner or later your mind will wander somewhere else, positive, negative, or neutral.” The goal of the exercise is not to empty your mind. The goal of this exercise is to recognize when your mind is hooked up by other things, and at that point, bring it back to your breathing. Constantly, as soon as you realize your mind is somewhere else, bring it back to your breathing. You develop this muscle-based skill of recognizing when your mind is going somewhere else so you’re not hooked up in rumination, hopelessness, and magnification for two hours, maybe for twenty minutes with less effects.
If the person doesn’t want to do a close eyes meditation, you can ask them, “You can make it more practical and functional when you’re showering, brushing your teeth, washing your pots, dressing yourself, walking, immerse yourself fully in what you’re doing.” Put all your senses varying what you’re doing, your eyes, sight, smell, and tastes. As soon as you realize your mind has gone somewhere else, bring it back to the activity. With this process of back and forth, you would get much more skillful at that and you will be able to recognize earlier on when your mind is somewhere else ruminating about pain.
It’s quite simple, the beginning of it. It is to help people notice what the flow and content of their thoughts are. Going back about pain catastrophizing by magnification, rumination, and helplessness, that helps us with a framework as far as practitioners to understand what’s happening inside the mind, but we can’t approach people with that because it’s too technical. Immersing yourself in a one-minute mindfulness exercise or taking that skill and using it with a simple activity like washing the dishes or walking the dog. Learning how to consistently take that skill of unhooking from the mind and coming back to the present moment versus running away with the mind. Pushing thoughts away and distracting from thoughts and that thought suppression in and of itself can lead to more distress.
That’s important because people do try to distract from thoughts. In certain traditions and other types of approaches, there is an approach to suppress thoughts but it’s like that beach ball under water. If you take a beach ball and you push it under water, as soon as you take your hands off, it pops right back up to the surface. The harder and more forceful you push the ball down, the more you try to suppress that ball, the higher it pops out of the water and our thoughts can be the same way, especially with regard to chronic pain. If we take this one cognitive process of cognitive defusion, and instead of applying it to people with pain, we apply it to professionals. If we apply it to ourselves as pain practitioners, how can cognitive defusion be a beneficial psychological skill for professionals who work with people living with pain?
People who work with a professional that works with people experiencing persistent pain can burn out more easily than people that work with other type of conditions. We know that some of these patients can be challenging and draining your energies as well. The symptoms are sometimes complex and unpredictable, we may find ourselves hooked up in types of thoughts like, “This is because of me. I didn’t things right. I should have done more. I’m not doing this right. What am I missing?” All these faults multiplied per all the amount of people you see, over the weeks, months and years do lead to a lot of stress.
A lot of people tried to calculate how many faults a person has per day. A paper a few years ago said between 60,000 to 90,000 faults is not right. A paper in 2020, who came out on Nature Communications stated that a healthy adult has around 6,000 daily thoughts. Most of them are negative. Imagine thinking, buying, dwelling, ruminating thousands of thoughts every day, week, month, and multiply, it’s a huge number of thoughts. When we work with people who have complex symptoms and required a lot of that help, the risk that we get hooked up with the story that we are not good enough, for example, can be detrimental. Applying these methods on ourselves can be beneficial and I invite everyone to do it.
With regard to ACT and cognitive defusion, do you approach cognitive defusion as a technique, or you’re looking at this more as a process that you’re guiding someone through as they’re going through therapy with you and learning about their pain?
As a process. Now, there is the cognitive fusion questionnaire in which you can have a better understanding of how much the person is fused with their thoughts. It may be useful, it maybe not, but I think it is useful to approach it as a process. When you’re asking your patient to do a movement and they are fearful of, start simply by asking them, “I wonder what is showing up in your mind? What is your mind telling you?” As you say, “What is your mind telling you,” you already are doing a little bit of defusion because you are implying that there is another entity communicating with them. What is your mind telling and showing you? What thoughts are coming up? You start appreciating getting a taste of how much they can defuse and what thoughts come up, and you can do something that is required. It’s not that everyone needs to have cognitive defusion done, but that is a useful tool for the vast majority of people.
As a physiotherapist, how did you come to adopt ACT into your care? When did that begin and what did that look like for you as a professional?
It began years ago when I burned out. I was experiencing a high level of anxiety and intrusive thoughts. I went to see a therapist and I told them the same thing my patients said, “I want to get rid of this. I want you to do something so I can feel better. I can start my life where I left it. I give my pain to you and you sort it out, then you give it back to me fixed.” Poor thing, the therapist was a great one, but it was not a good communicator. It was an ACT therapist, and he said, “We have to work on acceptance.” When he said that, I’m like, “Let me pay you and see you never again.” Instead, I remained there. He didn’t explain well because I said, “I don’t want to accept anything. I want you to fix it.” Session after session, it went better and better, and I remain fascinated by his approach. I said, “There is a lot of that we can use here in our patients.”
The distinction between pains, anxiety, depression, low back pain, neck pain exists only in our head. The processes that lay beneath these labels are similar to person-to-person because we are human beings, and we work the same way. In people experiencing pain, there is anxiety, not even people recovering from replacement. A lot of his processes are present in every person, even if the condition is different. ACT teaches us how to deal with the process. It is more of a process-based therapy rather than having a protocol, but it’s not a protocol that you apply to people. I found it is good that study about it, and since hypnosis is part of my clinical practice.
Davide, I’ve interviewed many psychologists, many pain physical therapists, many pain researchers. You’re the first person who has said the distinction between physical pain, anxiety and depression only exists in our mind. That is unique, and what we need to spread more of that message around. People who study this every day have yet to say that. It tells me that you’ve taken this work. You embody it for yourself and use it with your patients, but if we take that distinction that there is no difference between physical pain, anxiety and depression. How does that change what we do as physiotherapists? How does it change how we look at and how we treat pain?
In a lot of ways, there’s still a distinction between those three. We have ways to measure physical pain. We have the Oswestry to measure different aspects of depression and anxiety, but you’re saying, “This sounds great on paper, it looks great in a research study.” When you’re working with someone, you can’t parse out all these little pieces, like, “Let’s pick up physical pain and let’s put it here. Let’s pick up anxiety and put it here. Let’s pick up depression and put it there.” In essence, you have to treat these three together at once.
When it comes to medical practice, if you are a surgeon, if you are someone prescribing specific heavy drugs, you need to know what the diagnosis is. You give certain drugs for people with no susceptive pain and other types of drugs with people with other types of pain. When it comes to helping people, going back to their normal life, these labels lose their importance. We all speak about bio-psycho-social model of care and we have to move towards a bio-psycho-social model of care, but we are all stuck instead stealing the biomedical model of care because we still have this division between the mind and the body, the body and the psyche, the body and the soul. We still talk about psychosomatic pain, but I still don’t understand what it is.
There are psychological components. We have brain, with a psyche, so there are always psychological components in everything. What we need to do as a physiotherapist and practitioner is to try to diffuse from those false ideas and beliefs we have, and see what we have in front of us and see what they want to go back to. What life they want to live? What is important for those people, and what are the barriers between them and the life they want to achieve? We work on decreasing the barriers and we forget about the rest. If it’s nociplastic pain, fibromyalgia pain, primary chronic pain or secondary chronic pain, if it’s not a susceptive type of pain, we need to work on it. As Steven A. said and he published a couple of interesting paper on process-based therapy, not on a diagnose based therapy.
In your work now, are you still using pain education, or using it less? How do you approach someone when you have a bit of pain education in one back pocket, acceptance and commitment therapy in another back pocket? In your mind, do you have a framework or is it depends on the patient and what occurs in front of you?
It depends on the patient and what’s in front of me. For example, the lady I was mentioning before that came and said, “I cannot stop thinking about pain.” We started immediately with cognitive defusion. When someone who comes and see me and says, “I have this bulge, L5-S1, and that’s why I’ve been in pain for the last year.” I still tend to provide, in a mild and gentle way, some pain neuroscience education. There is room for both. Back in the days, I was lecturing people this is the way it works. The moment I think still providing some explanation of why varying pain is useful, and it works because evidence shows it works and people benefit from it. If I see that don’t bind to it, I don’t insist. I look more on how I can help that person to make sense of their experience and to achieve what they want to achieve in another way. I stopped fighting with them if I see that it’s not their point and it’s not fair as well. We have to convince you at every cost.
You mentioned with pain education, we’re delivering information to people, we’re sharing data with people. It’s more of a didactic approach. It’s a knowledge-based approach. Learning to pain where ACT is more experiential. These two things are different. What was that process for you to go from a more didactic to a more experiential approach to therapy?
I didn’t feel it like a problem. Alongside that, I studied as well in motivational interviewing. Motivational interviewing helps a lot in doing these because it helps deliver and communicate much better. It can be helpful even if you are not practitioner. It can be helpful if you are a pain neuroscience education practitioner to deliver the message across in a much better way. There is an interesting paper published by U&As on mixing pain neuroscience education and motivational interviewing. ACT is a more experiential approach. It involves a lot of feeling, being aware of things, getting in contact with experience, and that sometimes can carry some practitioners, some colleagues, because it feels like something much different from what a physiotherapist traditionally should do, or what we think a physiotherapist should do.
In this case, defusion techniques can help us to look from these things that are popping up in our mind, “We shouldn’t do this, this is not for us. Let’s leave it to the psychologist.” The patient will not understand but we are always concerned that the person comes to us because they want something. They want to be manipulated, massaged, stretched, needled. The person comes to see us because they want to be better, they’re stuck and they don’t know how to get out of the quicksand on their own, otherwise, they wouldn’t see you. They’re open to anything that can help them. It’s down to you, the practitioner, to deliver this message in a good way, skillful way, professional way, and help them understand that maybe other things can be more useful for them.
We’ve been talking about the mind, and how the mind can influence pain negatively, as well as positively. You’re way ahead of many people with regard to using the mind in clinical practice. People still aren’t using the mind. It’s still considered a radical approach for a physiotherapist to use the mind, or for a primary care physician to talk about the mind and talk about mental skills training with regard to pain. Why is this still considered a radical approach with regard to the treatment of pain?
I grew up with my grandparents. When I was a kid, I spent a lot of time with my grandparents and I’ve always been fascinated by my grandmother. She had seven kids, and she had three miscarriages, two of them died when they were young and one of them was a teenager when she was fifteen. She had a lot of horrible things that happen in our life. Despite that, I’ve always seen her cheerful, happy, always with a smile on. That does not reflect what is going on, but she lived and she’s still living her life at the age of 90, and she’s almost blind and deaf in a full way. She did everything she wanted to do.
I saw her thriving and living a full life. I asked myself, “Why is there are people that are so flexible to the circumstances, but are other people in a certain way, appear to be the victim of the circumstances? What if we can teach these flexibility skills to people?” At the end of the day, it’s not about what happens to you, it’s about how you react to it. That is something that is well said in the Buddhist teaching. It’s not about the circumstances, but your relationship to the circumstances. What if we can teach from something to teach our patients in pain to relate in a different way from what is going on? Yes, we may not be able to change pain. Unfortunately, in 2020, there is not a cure for chronic pain.
Chronic pain, in some case, it doesn’t get better. In some case, it lasts, it gets even uglier, but we can help those people to develop these flexibility skills through acceptance commitment therapy, for example, so they can have a better quality of life and they can live the life they want to live, a full, vibrant, meaningful life despite the circumstances. That’s why it is important and relevant to teach psychological framework like acceptance commitment therapy that teaches psychological flexibility to use within your clinical practice with people in pain and not all are the same.
I have been with Davide Lanfranco. He is a physiotherapist in London, originally from Italy. I want to thank him for joining us. Davide, let people know how they can learn more about you and follow your work.
Thank you. They can follow me on social media, on Facebook, Twitter, LinkedIn, Instagram at the platform of FisioScience International, that is a platform that me, together with other colleagues run about delivering and it’s about spreading evidence-based rehabilitation only. You can find us on all our channels.
Thanks, Davide for giving us an excellent talk on pain catastrophizing a cognitive defusion. Make sure you share this with your friends and family on Facebook, Twitter, LinkedIn, or wherever anyone is talking about acceptance in commitment therapy and pain education. We’ll see you next time.
- Chartered Society of Physiotherapy
- FisioScience International
- Radical Relief
- Davide Lanfranco
- Pain Catastrophizing
- European Journal of Pain – Article
- Nature Communications – Article
- Facebook – FisioScience International
- Twitter – FisioScience International
- LinkedIn – FisioScience International
- Instagram – FisioScience International
About Davide Lanfranco PT, MCSP
Davide is an Italian physiotherapist who has been working in London over the past 5 years. he is a member of the Chartered Society of Physiotherapy and of the Physiotherapy Pain Association. He is one of the founder of FisioScience International, an online platform which aim is to spread evidence based rehabilitation.
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