I attended a workshop back in March that has changed the way I practice forever. I wrote briefly about it here, but I've been trying for the past couple of weeks to wrap my head around the message and say something useful about it here on the blog.
Then I realised that I was being an annoying perfectionist and I should just write the damn post.
So here are my partially-digested learnings (it's less gross than it sounds... really) from that day. I'll be talking a lot about pain rehabilitation, but the applications are much broader.
We're doing it wrong...
In the land of vocational rehabilitation, our path forward is dictated by medical certification. A lot of our time is spent clarifying expert medical opinion on what our clients can and can't do.
All of this makes sense when we're working with a person who is on a normal path to recovery and is keeping up with the expected timeframe of when they will get better. The reality is that so few of these clients ever get referred to us - because they got better and went on their way.
Most of our clients are dealing with protracted injuries and chronic illness.
Beyond that, they have a cacophony of social, environmental and psychological "stuff" happening in their lives as well. Timeframes and rigid capacity upgrades just don't work here because there is so much more going on.
In rehab, you might feel like you're banging your head against a brick wall in these situations.
And maybe you keep getting stuck in circular discussions that never. go. anywhere.
Me: So Mr. Doctor, when can Mr Peabody start thinking about work again?
Frustrated doctor: When he is in less pain.
Me: We've been trying to fix Mr Peabody's pain for a while now. What else can we try?
Slightly more frustrated Doctor: He is in too much pain for us to do anything. Let's not do any more activity until the pain is better.
Me: So what do we do in the meantime?
Very frustrated doctor: ¯\_(ツ)_/¯
That was a real discussion I've had. And it's not an uncommon one.
I can get mad at the medical model all I want, but I was making a mistake here too. We all were.
We were all focusing on fixing the problem instead of helping a person live their life, now.
An Un-winnable War
If you have 45 minutes to spare, you really (really) need watch this video from Professor Kevin Vowles.
Then, you have to come back and tell me whether you agree with this statement:
Helping people live better lives is not about fixing their injury, their illness or their pain when experience (and research) tells us that this may not be possible. Our job is to help people do what matters, with or without the pain.
And in the case of chronic pain... treatment attempts have proven to be futile.
So this calls into question whether our obsession with improving "capacity" is of any use if our definition of capacity relies on pain reduction.
Will any of this actually help our clients live better lives, or re-engage with their community and work again?
Research tells us that:
- Opioids do a terrible job at long term pain reduction.
- Ongoing pain and disability after surgery is the norm.
- Treatments and surgeries that do produce a reduction in pain tend to have no meaningful impact on disability or function.
What does this mean?
When people with chronic pain pursue conventional (and not so conventional) approaches to a cure, the longterm gain is negligible.
People are a little more comfortable, but they continue to miss out on life.
Giving up the "good" fight for something better
When our clients come to us, they are fighting the fight of their lives against their pain. Their pain has taken so much away from them: their vitality, their relationships, and their work (just for starters).
This makes perfect sense: as humans we're wired to avoid pain because pain means danger.
Pain demands attention.
But for people with chronic pain, those pain signals don't necessarily mean danger anymore. But anyone with chronic pain will tell you that the experience of pain can be unbearable. So often, people stop doing anything that might rouse the pain monster once more. They halt the activities that might aggravate their pain.
The cruelest part of all is that these attempts to stop the pain don't actually work in the long term. Perhaps even crueler yet is that these perfectly normal attempts to avoid pain also mean that a person becomes isolated from the activities and people they once felt connected to.
You may be anticipating my next point...
What if we gave up the struggle against pain to make room for something else?
I know - how trite. How could anyone like the idea of giving into pain?
But "giving in" is the opposite of what I mean. Here's an example that Prof. Vowles gave in the workshop:
Living with pain is like walking around with your finger in front of your face. All you focus on is that finger - what it means, what it's done to you, and how you can get rid of it. As you walk around, your attention is directed only at the finger, so you miss out on potential opportunities to engage with something else - something you value.
Our current approach to treating pain is like trying to chop off that finger. But again, research tells us that this is easier said than done. And the costs of this approach result in long term disability, pain and loss of function.
Noticing what else is there.
Try walking around again with that finger in front of your face, but look beyond it. Can you see what's around you again? Are you making better decisions about where to turn and what to do next? Are you noticing more?
What we can help people be on the lookout for are opportunities to engage with the things that matter to them even when the pain is there.
From Prof. Vowles again:
Thus, the issue is not to just “accept it”, but to determine if there are areas in life worth the experience of pain. In my clinical experience, people with pain can readily identify these areas, desperately want to return to them, and agree that these areas matter even when pain is present. Such patient sentiments can allow further conversations about whether treatment might usefully include valued activities and progress towards them as a marker of treatment success.To summarize, from one perspective, the purpose of treatment is to allow patients to engage in activities that allow for a quality of life sufficient for their needs. It is within this purpose that acceptance of pain can be relevant – sometimes greater acceptance of, and consequently less time and energy spent struggling and avoiding, pain may free up behavior to allow for the pursuit of what is valued. 
Preliminary evidence from this approach is promising: people with chronic pain who are supported in re-engaging with activities that align with their values experience better functioning and quality of life. 
What could this do to reduce the amount of suffering that comes with ongoing pain?
What could this mean for our clients who have put their lives on hold, waiting for a promised cure that may never come?
What does this mean for the way we currently approach rehab?
References and further reading:
 Professor Kevin Vowles @ NeuRA: What is acceptance of pain and why would anyone want it?
 Scott, W., & McCracken, L. M. (2015). Psychological flexibility, acceptance and commitment therapy, and chronic pain. Current Opinion in Psychology, 2, 91-96.
Manage Your Pain: Practical and Positive Ways of Adapting to Chronic Pain.
McCracken, L. M., Vowles, K. E., & Eccleston, C. (2005). Acceptance-based treatment for persons with complex, long standing chronic pain: a preliminary analysis of treatment outcome in comparison to a waiting phase. Behaviour research and therapy, 43(10), 1335-1346.