498: Laura Rathbone, PT: ACT in the Clinic

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Laura Rathbone on the show to discuss Acceptance and Commitment Therapy. Laura Rathbone is a Specialised Pain Coach and Advanced Physiotherapist that works exclusively with people experiencing persistent pain and conditions such as chronic back pain, pelvic pain, fibromyalgia and CRPS.  Much of her work is virtual as she coaches people all over the world in the service of their pain, but she also has a small clinic in the beautiful town of Weesp, just outside Amsterdam, the Netherlands.

In this episode, we discuss:

-What is Acceptance and Commitment Therapy (ACT)?

-How the ACT framework compliments a biopsychosocial approach to patient care

-The importance of promoting active over passive interventions for patients with persistent pain

-Why clinicians should integrate psychologically informed physical therapy into their practice

-And so much more!

 

Resources:

Laura Rathbone Website

Laura Rathbone Twitter

Laura Rathbone Instagram

Laura Rathbone Facebook

Laura Rathbone LinkedIn

The Association for Contextual Behavioural Science

 

A big thank you to Net Health for sponsoring this episode!  Learn more about Four Ways That Outpatient Therapy Providers Can Increase Patient Engagement in 2020!

 

For more information on Laura:
Laura Rathbone is a Specialised Pain Coach and Advanced Physiotherapist that works exclusively with people experiencing persistent pain and conditions such as chronic back pain, pelvic pain, fibromyalgia and CRPS.  Much of her work is virtual as she coaches people all over the world in the service of their pain, but she also has a small clinic in the beautiful town of Weesp, just outside Amsterdam, the Netherlands.

 

She understands the need to see people from a 'whole-person' perspective and integrates modern, evidence-based physiotherapeutic and psychologically-informed approaches.

 

Laura is a UK chartered Physiotherapist and has a Masters Degree in Advanced Neuromusculoskeletal Physiotherapy from Kings' College London.  She is part of the Le Pub Scientifique team which organise regular live learning sessions exploring the science of pain and produces a small podcast called “Philosophers chatting with Clinicians”.  She runs her own courses on ACT and mentos clinicians regularly.

Read the full transcript below:

Karen Litzy (00:01):

Hi, Laura, welcome to the podcast. I'm very excited to have you here and today we're going to be talking about ACT. So thank you so much for being on the podcast.

Laura Rathbone (00:12):

Well, thank you for having me. I'm excited too. I like talking about something.

Karen Litzy (00:17):

All right. So now let's talk about ACT first, two questions. What is ACT and how did your interest in ACT come about?

Laura Rathbone (00:32):

So ACT stands for acceptance and commitment therapy. I suppose, you know, sort of efficiently, the way we talk about it is that it's a third wave cognitive and behavioral therapy. So it's born out of the behavioral movement and it's a psych it's essentially, it's a psychology framework. It came out of the world of psychology. And the aim of it is to recognize that when we are experiencing, you know, difficult unpleasant and invasive stuff, there's often a lot of all the aspects to that experience that add to the struggle and add to the suffering. And what we're working with from an ACT perspective is often can we compassionately and you know, empathetically and appropriately work with some of that, all the stuff that comes with the struggle and comes with a difficult experience. And does that help us manage our present moment experience?

Laura Rathbone (01:38):

Does that help us reduce some of the suffering so that we can move forward with some of the realities that are in our lives? Like for example if you're experiencing pain, which is where I come into it, you know, in the absence of having a really good predictable, effective cure for things like persistent pain, things like fibromyalgia, CRPS even chronic low back pain, which we, what we don't have these predictable sort of treatments that's going to take that away once the pain has started to become resistant, but in the absence of that, are we able to support people with their pain so that they can thrive. They can be a person who has pain and has a career and has a committed family life and has a social function and role, and they're able to thrive with it. And that's really what we're doing with ACT there.

Karen Litzy (02:38):

And where did your interest in ACT come from? How did you get involved?

Laura Rathbone (02:45):

Yeah, there were two answers to that really. First answer I guess, is that I just sort of fell into it like so many people, right. I graduated from university. I went into my first job. I had a really difficult first job experience in a difficult company and ended up working, noticing, I suppose, and working with people that had persistent pain. And so I was constantly seeking for better solutions and trying to figure out how we can do better by these people. And then I guess I just sort of navigate it that way naturally. And yeah, so I was interested in mindfulness, mindfulness, you know, you study things like the MBSR. So the mindfulness based stress reduction start thinking about how you can incorporate bits of that into practice. And before, you know, it, you end up into accepted therapy.

Laura Rathbone (03:41):

And then I was super lucky because I managed to get this brilliant job in the national center for pain at st. Thomas' hospital in London, where I was working at input, which is the pain center. And I was working underneath professor Lance McCrackin in their embedded ACT unit. So I got this great opportunity to really further my training and understand how it functioned as a framework and how we as physiotherapists could really be maximizing our therapeutic alliances and relationships and really integrating this model to create, you know, a psychologically informed approach, if you want to call it that or a compassion focused approach so that we just do better by people who are vulnerable and in pain.

Karen Litzy (04:26):

Well, that makes a lot of sense to me. Thank you so much.

Laura Rathbone (04:31):

If I was to give you a second answer, is that, you know, pain is a bit of a personal experience. It's a personal journey for me. My mom had chronic low back pain when I was younger. And I guess I'm only just now coming to terms with the influence of that on my career. Something that I haven't talked about a lot. But I do get asked about quite a lot. And you know, it would be silly to say that those early experiences of somebody with chronic pain, you know, didn't have an influence on me and seeing her go through a biomedical approach to treatment and not be heard and seeing her struggles and thinking, well, you know, and the injustice has probably built in me as the second generation and thinking, well, how do we restore some of that justice? And then how do we acknowledge that there is an imbalance here in terms of privilege, like clinician privilege versus patient privilege, and how do we start to restore that and make sure that we listen to the people we work with and do better.

Karen Litzy (05:36):

What sort of experiences did you see your mother go through that kind of led you into where you are today, when you say so for a lot of people, they might not be familiar with the biomedical approach and what that looked like, but what did that look like for her? And then what did that look like for you as a kid growing up?

Laura Rathbone (05:58):

Yeah. Like I say, something that I'm still really coming to terms with then, and the memories of what I saw my mom go through was still quite like emotionally charged. They're still very close. And we're talking about it, me and my mama talking about this more and trying to open it up a bit more and explain that. And then what I remember, you know, being in the car and my mom being unable to sit in the chair and the sound of her voice when we went over a bump or the car stopped that, that Yelp for pain, that, that real yeah. Terrorist pain really. And I remember her spending hours in the bedroom, not being able to get out of bed but, you know, she also, she was an amazing woman, you know, incredible first role model as a strong woman, really, because, you know, she's a nurse, she was working in the pediatric units, she's done everything really she's done a and a pediatrics domiciliary, which is community-based working.

Laura Rathbone (07:04):

And like, she used to get up every day, even in pain. And she would go to work in paid and, you know, do all these and just push and push and push until she was exhausted. And when she would be like posted on the weekend and then pushing herself and through the day, and I saw her just be hopeless. That was, I think the overriding feeling, if I really reflect quite personally, was that feeling of, there is no hope there is no way out of this. This is the norm and resigning to that. And that's because, you know, she'd tried physical therapy or physiotherapy in the UK. And, you know, she'd tried like acupuncture and she'd gone around the holistic meds you've been in and out of the doctors and things like that. And just really been told there's nothing that they can do, but yet also she had this image of why she had pain. So she was told that she had back pain because her Coccyx had dislocated during labor, which was my labor. So there's a bit of personal guilt as well.

Laura Rathbone (08:07):

And really those things where, like, she always felt that that image had stayed with her forever. Even now, probably if you talked to her and ASCO, which we were working through a little bit, which is hard to do an issue, mom, I, you know, trying to figure out what, how she views her body and her back is becoming a much stronger image, but she really had to find her own way out of that. And it was years later until she found a solution that she could, she felt she could predictively start to acknowledge and manage her pain. And, you know, it's not the traditional method that she found a kind of like a kind of massage tool, which is everything we wouldn't say right now, but it worked for her and it gave her a freedom. She felt all of a sudden I have something I can do when I have pain. And that was the most important moment for her. And it wasn't, you know, acceptance and commitment therapy or mindfulness. It was, it was a tool that gave her strength. It was a kind of extended part of her own ability to self manage. And she did that and it worked for her and I don't advocate those kinds of mechanisms and those approaches, but it worked for her. And there's something in that. There's something important in that. But yeah, I remember I remember her pain and yeah, it's still very personal.

Karen Litzy (09:27):

Yeah. And not easy, but thank you for sharing that. Cause I know that sharing personal experiences from my personal experience is not an easy thing to do, and it's not easy to put that out there where the world is going to hear that. So thank you. But I'm glad that you shared it because I guarantee you, there are going to be people listening to this podcast who are going to say to themselves, that's me. That was my mom. That's my sister, that's my friend, that's my patient. And so I think it's really important to allow the listeners to understand the magnitude of hope and of finding something that works for you, even if it's not physiotherapy or it's not XYZ doctor or whatever framework you're using. Because like I said, somebody out there is going through that same exact thing. And just to kind of hear that story and to hear how, not only did it affect your mother, but it affect you and your family and growing up and I think that's a really powerful share. So thank you.

Laura Rathbone (10:35):

Welcome. And thank you to my mom who continues to be an incredible voice in my growth as a person and who went through that journey and who still goes through that journey. Although she doesn't identify now as somebody who has chronic pain and that's a great moment for her, like she's now able to do so much more and really doesn't have back pain very often anymore. So, I guess the, you know, yeah, it's hard for me to share, it's not my story.

Karen Litzy (11:11):

Yeah. Yeah. Well, and we're going to get back to pieces of that story in a little bit, but I heard you say in the beginning of this podcast, talking about ACT as a framework, I would like to kind of bust a myth because I think a lot of people look at it as a tool to put in the toolbox. So what do you say to someone who's like, Oh, ACT, this is a great tool. I put it in my toolbox. I'll take it out when I need it.

Laura Rathbone (11:45):

Yeah, this is, Oh, I'm glad, I'm glad we're talking about this. Cause this is something that this is probably my personal opinion and there's probably people out there are acceptance and commitment therapists. You may disagree with me and that's absolutely fine this space resolve, but I do not think that ACT is a tool that we pick up when we think it's appropriate. First of all, how do we know that? That's certainly another thing, isn't it? You know, we don't, you know, and what I would say that acceptance and commitment therapy is how we are. It's a way of being with your clients and the people who choose to work with you in the service of their pain. It happens. It's how we make decisions. It's how we think about and how we facilitate those decisions and how we are part of, you know, the next step in that person's journey.

Laura Rathbone (12:37):

It's not something that we say, Oh, we've exhausted the biomedical approach. Now we're going to pick up the ACT approach. And it's a bit later the biopsychosocial approach that it just doesn't work like that. This is just another way of, you know, clinicians getting out of doing the hard work, which is listening to people's stories and empathizing and putting themselves in somebody else's shoes and trying to, you know, trying to get more of their life experience as opposed to showing off what they know about a particular joint. Like this is not how we work in pain. Pain is a very personal, it's a very unique experience. It's built off of life experiences, as well as memories and, you know, learning and worries and fears and all of that plays out in our physiology.

 

Karen Litzy:

And what can a clinician who's working with someone in pain and they are taking the ACT framework into the clinic. What does that look like?

Laura Rathbone (13:41):

Good question. Yeah. I mean, I guess it depends what your setting is, doesn't it really like if you’re setting is first line, so people are coming to see you and they have never seen anyone else with that problem, then of course, we're going to be thinking, okay, where is that person in the journey from that injury or the onset of their pain? Are they two years down the line? And this is the first person they see, or are they two weeks down the line? Cause that always is going to affect your approach to assessment and monitoring really. So it would make a difference in terms of where you start, but you're always thinking about okay, so if this person is two weeks from injury, then you're going to be doing your injury based assessments, your pathoanatomical approach to assessment.

Laura Rathbone (14:34):

And we want to want to make sure that this person hasn't done any serious injury. And we want to make sure that we, you know, use the most appropriate and effective science that underpins our physiotherapy framework. Right. But you're still thinking, how is this person managing this injury? You know, even though we might be assessing the tissue in some aspects that tissue belongs to a person it's in a human it's in a much wider system. So we're always going to be thinking, okay, and how is this person dealing with the fear of an injury? Are they able to make sense of this in a helpful way, are their behaviors of management helpful or unhelpful? And if they're unhelpful, then how can we facilitate an experience that allows them to update that behavior into a more helpful way?

Laura Rathbone (15:29):

And that's what we're doing with that all the time. So I guess in my setting, when people have probably been through lots of healthcare professionals, then I'm going to that it would probably look quite different. I would use ACT maybe in a more intense way from very early on. Whereas if you're in a very acute injury setting, you're going to be using it as part of your assessment. You are still going to be satisfying, those more traditional approaches to injury assessment and management, which is not my area. So I don't want to make assumptions.

Karen Litzy (16:24):

Right, right, right. Of course. And what is, let's say a patient has come to you and they've had a long history of pain and you're sitting down, then this is the first time that you are seeing them. What are some questions? I know this is, I'm using this very broad net here. We're casting a very broad net because obviously the answer is, it depends on the person. And I want everyone to know it depends on the person, but it depends on the person, but for people listening to this and not really quite grasping, that sort of ACT framework is there. I don't want to say an outline, cause I don't think that's the right word for it. It's just escaping my head at the moment. But can you give examples of maybe how that conversation might go or what you're trying to, to get from the person in front of you using this framework? And again, we're talking about people with more persistent or longterm pain problems.

Laura Rathbone (17:11):

Yeah. So when somebody comes in and sits down and starts telling me, you know, what their lived experiences of pain and they start in their story, wherever they feel is the most important place to start. And we give space for that to grow. I guess what I'm looking for, what I'm trying to pay attention to is you know how is this person making sense and applying meaning to that pain what is it that they're coming to me for guess is the first thing, like, what is it that they're here looking for? Are they here looking for something that I can't give them, in which case I need to be really open and honest about that? Or are they coming here because they're looking for they're wanting to move towards a particular goal.

Laura Rathbone (18:07):

So it, usually people come in and they're telling me about that pain. And of course that's really, really difficult as a person. Sometimes it's really difficult to listen to, to hear somebody else's pain. So I'm mostly working with my own resistance, but also thinking well, okay, what is it that how we want to find out? What is it that would, would give this person that would help this person find more joy, more meaning, what is it, what is the value that they want to move towards? And what is the struggle that they are coming up with? So, so where are they getting stuck? Like, what are they battling all the time? And I guess that's where the idea of acceptance comes in and an acceptance here is really not resignation. It's really not just, you know, getting on with it's an opening up of the experience to accept that there are difficult and painful and hard to look at experiences happening in the present moment. And so we're opening that opener and sort of acknowledging that those things are there. And also maybe giving space for the fact that there are other experiences beyond those as well, that there's a wider spectrum of experience here. And trying to find a way to be with those experiences and also be with the important things in your life. This is what we see commonly. And what we hear with in the clinic is that people who have, you know, people who are experiencing pain are also missing out on a loss.

Laura Rathbone (19:51):

And that's really, really, I think what a lot of people find the hardest. And when I listened to it, you know, what the people who choose to work with me say, it's actually that they're just grieving that they're unable to be part of their family moments or their community or their society, or, you know, the things that they really believe in and that they really want to be part of. And it's hard because when they go into more traditionally biomedical models, the clinicians are saying, Oh, well, when we've done this surgery, your pain will go and you can do that when we've done this injection, when we've done this treatment and, you know, yeah, great. If that works, then that's an absolute lesson relief and fantastic. But what if someone's been doing that for 10 years and the clinicians are still saying, well, when we do this treatment, your pain will go when we do this treatment, you know, you starting to chip away at someone's life.

Laura Rathbone (20:53):

You know, this is a lifetime that easily limited, you know, we don't have infinite lives to live infinite moments to be part of our job and probably the most significant part of our job, especially in persistent pain is helping people and facilitating opportunities for people to be part of those moments. And to make sense of their life in a wider spectrum, rather than just, how does my life make sense in pain? It's more like, how does my life make sense in the whole bio-psychosocial sphere? Am I able to be part of that? And that's what we're looking for, or certainly what I use acceptance commitment therapy for. It's a way of creating opportunities and creating space for us to support someone as they take their pain into really, you know, meaningful moments and find that there can be joy as well as pain. And that is a really, really difficult thing to acknowledge and to allow for when you have pain, because it means that in one aspect of your pain journey, you have to allow yourself to take a step forward with it. And that's really hard if you really want to get rid of it. And of course we should always be working towards that. That has to be a big part of our approach, but it might not be the only thing we focus on.

Karen Litzy (22:27):

I'm glad that you said that because you sort of jumped the gun on what I was about to say, because when people come especially to a physical therapist or physio, one of the main reasons they're coming is because they have pain, right? And so they're coming to us to quote unquote, fix it, fix the pain. I don't, once I don't have this pain, what's your goal. Zero out of 10 pain, no more pain. And so I think from the clinician standpoint, when you have those people sitting in front of you, it's very, very difficult to have those conversations of, and you say, well, what if you still had a little bit of pain, but you can do XYZ activity, or you can still take part in all of this stuff. And you can expand those areas of your life, even though you have pain.

Karen Litzy (23:26):

Is that the wrong thing to say to someone is, should that be a goal to work toward, or should the goal to work toward if their goal is 100% no pain, what does the clinician do? What do we do with that person in front of us when maybe we may think, well, but you can X, Y, and Z, and you can have this full life. If maybe you have a little bit of pain, but the person in front of you is very adamant and their goal it's no pain or nothing, no pain or bust. So, how do we, as the therapist navigate that? Cause that's very tricky because like you said, we're working towards reducing pain, but what if that's not enough?

Laura Rathbone (24:13):

Yeah. So this is a really difficult part of the conversation, isn't it? And I guess what happens probably more often is we come up against our own reflex to save everybody in front of us and our own reflex to be sure we know we are right, right. Our own privilege that we are the experts, but we have no idea what is right for that person in front of us and what is enough for them. And, you know, in the first few sessions, when you meet someone, you’re still in the process of relationship building and trust building. So those early conversations may well be communication of, you know, I am really struggling with this pain. I am really suffering and I need you to fully acknowledge that I am really suffering with this pain. And it may be a way, you know, and that might be that that's where that person is.

Laura Rathbone (25:14):

And it might not be that we can change that. And I put that in quotes because you know, what we're doing here is where we're with a second sense and commitment therapy specifically is we're coming from a place of no judging. So, what the behavior, the thoughts, the meanings of that person's coming off of, I have no idea if it is right or wrong for that person to keep seeking, you know, a hundred percent cure. I mean, I looked to my own, my own experiences and see how far people I love and in my direct family have come in their chronic pain journey and think, well, you know, I have no idea if it's going to be a cure or if it's not, if there is such a thing, I mean, we're thinking of cure. The word cure is almost decided that we know what the cause is.

Laura Rathbone (26:00):

And we don't fully know that yet. So we don't know what the end point of that person's journey is. All we can ask is right now, is this helping you in this moment as we take a step in this part of your journey. And if that's unhelpful, because it's not helping us to take a step in the direction that we've highlighted is a good one that you've decided you want to take, then we need to work with that urge that keeps coming in to go for a curative treatment, potentially curative treatment. If we've got one.

Laura Rathbone (26:36):

But I guess what I would suggest in that moment is that we as clinicians probably need to do the most work because our urge is to jump all over that and be like, no, no, no, no, no. The science says that you're never going to get that. And that's a cruel message and it's not accurate. We have no idea. You know, our urge is to educate the shit out of that person and make them feel better. Right. But we don't know. We don't know that. So maybe we need to sit with our allergies a little bit more. Maybe we need to pull ourselves back a little bit more in that moment and just hear what that person is saying and listen and acknowledge it and bring it into our decision making, bring it into our understanding about, you know, what that person is going through.

Laura Rathbone (27:19):

What in our experience might be a helpful step. And then we have that collaborative discussion. Do you think it's going to be a helpful step? Would you like to go in this direction and see what happens? See what comes out of it? It's hard because we are trained to know the answer. That's what that biomedical model is all about. Those, you know, assessment tools. We can tell you if you've got an impingement and you know, that the idea, the whole point of that is that we had an idea that we knew what was causing pain. We knew it was the musculoskeletal system, and we knew it was the nervous system. Then now we're starting to think, well, maybe it's the neuro immune system. And, you know, it's all this idea that we know what is the cause of a human beings pain. And I'm not sure I have seen any evidence that we're much closer. And that's just my opinion on what I see. So maybe in those moments, we need to check ourselves a little bit.

Karen Litzy (28:27):

And thank you for that. That makes a lot of sense. And you know, it brings me back to this idea that are we doing the best we can for the person in front of us at this time with the knowledge that we have and that has to be enough at that moment because that's what we have.

Laura Rathbone (28:53):

Yeah. And I think that's really an important thing to remember is that we are both two humans interacting on a human issue, which is the human experience of pain. And, you know, we are healthcare clinicians, not heroes, right? We're not the saviors, we're not in the, you know, the people that come to see us, they're not victims. They are humans trying to live their lives. And we are people who have studied physiology and people who have studied rehabilitation and people who hopefully are studying sort of communication and behavior change theory and the philosophy of just like a human experience. And, we're hoping that when those two things come together, something happens and the person who is struggling to come to terms with their pain, manage pain and find ways and solutions to their pain, right. We're hoping that the combination of these two things or these two people, these two worlds and worldviews come together and we can find and facilitate a way for that or the person, the person in front of us to move forward.

Laura Rathbone (30:03):

So, you know, yeah. We have to sort of remember that we are only doing our best and that has to be recognized on both sides, right. That there is also a responsibility for the people that choose to work with us to remember that we are people, we are humans. We do sometimes get it wrong. We are able to look back and say, Oh, that was not necessarily the thing that I would do now. And were able to change and update and evolve. Yeah, I guess that's where I come, that our job, our role is to make sure that we are reading the literature, that we are going to the podcast that we are listening and learning and evolving and evaluating our messages to say, is this still the best I can do? You know?

Laura Rathbone (30:52):

And to that end, I would say, I've had this conversation a few times with sort of new graduate clinicians who say, Oh, but you know, this person, I educate, I gave them the education and they just didn't get it because education has also been one session. And I say, okay, so you gave him the education. How did you deliver it? What was your approach to education delivery? You know, what training have you done in educating? And they touched, they took a weekend course, but if they've even done that, that's the point, isn't it. I try the CBT approach. Okay. So how did you train in CBT? What is the CBT approach? Yeah. You know, Oh, I've done mindfulness. Okay. So how do you integrate mindfulness since you're into your practice? And we say that we think that we know how to do these things, but we're not putting in the time and the effort to really fully train and upscale, you know, acceptance and commitment therapy is an entire psychological framework, right?

Laura Rathbone (31:53):

It's not a little bit that we just add in, it's an entire framework of being with the people that means you never finished learning. Right. I'm still learning. I still have people call me at my clinic and watch me. I still do peer review and make sure that people, people are listening and helping me understand how I apply ACT. And when I may say, or when I get it wrong. And so I can keep evolving, you know? And, that's the thing, isn't it, you know, we have to make sure that we are fully invested in our communication strategies, not just superficially, because otherwise we're not doing the best by the people that we work with. We're giving them a half-assed attempt at education, blaming them for not understanding what we were trying to say.

Karen Litzy (32:40):

Well, we don't even understand it. And, also being very cognizant of the fact that people communicate differently and people learn differently. So if you're giving quote unquote giving the education, well, I told them all about it. Well, maybe they're visual learners. Maybe they need to hear things in small chunks, not vomited all over with information, maybe they need follow-up. Maybe they need to watch videos. Maybe they need to take a test. Maybe I know I'm the kind of person who I like to take a test. It's a very weird thing. I took a continuing education course the other day on child abuse. And at the end, you know, they tell you to evaluate the course and I do. I'm like, well, where's the test, where's the test. How do they know? I know that I read. And my boyfriend was like, are you advocating for a test? Like you want to test?

Karen Litzy (33:32):

I'm like, yes, I want to test because I want to make sure that what I read that I understand it at least superficially right. So when you're talking, like I have had patients where I have explained things, explained pain, used a pain education approach to them. And I always try and follow that up with, you know, I'm going to send you a couple of videos. I'm going to send you some you know, and ask them like, do you understand? Can you kind of give me the highlights? What did you take away from that conversation? So you may educate them, but if you don't ask them well, what do you think? What did you understand from that? Does it matter what you said to them? If they can't understand a word that you just said?

Laura Rathbone (34:20):

Well, that, I mean, that is like one of the basic basic principles, isn't it of how do we communicate it? Does the other person even understand what we're saying? Are we using it an appropriate approach to communication? But I guess the other thing is, you know, the beauty of the ACT is that it came out of, you know, this struggle that we had in real time, behavior change, you know, like we can help people change their thoughts and they can change. They can, they can find a new narrative, but when pain comes, what do they do? What do we do when something difficult shows up, you know? And the skillset, in fact, the hex of flex, all the processes have changed at all. Within the hacks effects are there to be navigated and to be utilized in that moment, when pain comes, what do I do?

Laura Rathbone (35:19):

Is this helpful? Is this in service of something that I am working towards and not working towards, but that's, whatever the person in pain says it is, right. That's not all saying, Oh, we're in rehabilitation. Therefore we need to rehabilitate you to action. Or, yeah, I have no idea. You know, it might be that in that moment, the most important goal for that person is self care, right. That could be, I mean, and that's very legitimate and very, very valuable, you know, it's not, well, when pain comes, how do I push through it? It's what we're trying to figure out is okay, when your pain comes for you, what do you do? And is that helpful? And if it is, then all we want to do is facilitate that and to validate it. And if it's not helpful, then that's when we might say, okay, so how do we start opening this up?

Laura Rathbone (36:11):

How do we start finding a helpful thing? What do you think could be helpful? And our job is to facilitate that conversation so that the other person doesn't feel they are making all of the choices on their own. And they've all of a sudden, they've just had been dumped the responsibility of their own care on their lap. Our job is to compassionately titrate that conversation, what might be helpful, and to take our time, to explore it in a way that people feel they're able to meet in a way, not that people feel sorry, that isn't the right word in a way that people are able to make their own choices. And we are able to support them. That's it? And that's what ACT is.

Karen Litzy (36:55):

And to that end, I want to go back to the story of your mom and how you said she found this massager that really helped. And you know, you and I had a conversation the other day, and we had this conversation about the passive versus the active modalities and passive bad, bad, active, good only thing we should be doing. So let's talk about that within the ACT framework of your mom found a massager or whatever it is. And boy that really helped. So from an ACT framework, how do we make sense of that when we are supposed to be only advocating for active, active choices, not passive modalities, not a tens machine, not a massager.

Laura Rathbone (37:47):

Okay. So I would say this is probably the part of the podcast where I will, it's the most controversial part. Because if you are a person that advocates hands off therapy, then actually fit very nicely into your framework and you might be using it very X and you know, and doing great work. And if you are a hands on therapist, then you may have already decided the ACT is for the hands off people. So you're not going to go near him. And you know, my opinion on this probably changes quite often, but I would say that if a person is making an informed choice about how they, their pain that is helpful for them, that is active treatment, that is an active decision, but is that person and saying, this is helpful. So, I guess if we're going to use the way I would use ACT in that moment as somebody who typically doesn't use a lot of hands on therapy or a treatment delivery devices.

Laura Rathbone (38:58):

So we say, you know, I did my masters in sort of neuromusculoskeletal therapy. We did all the manual therapies stuff. I would say, okay, how much does it help? Let's talk about that helpfulness, because that's important because my job is not to make you feel bad about using something that helps you in your life. My job is to facilitate that and to support that and to see value in the bits that you might not be using, or the bits that you might not be doing. So if that person is able to say this right now is the only thing that is keeping me going, then we say, okay, it's helpful right now, helpful right now doesn't mean helpful forever. Right? Helpful right now means in this moment, in this context, with the knowledge that you have the skills that you have, the relationship that we are developing, this is very helpful.

Laura Rathbone (39:58):

So I'm not going to take that away because that's cruel, right? That's not nice. What we're going to do is we're going to work with that. I'm going to keep checking in and seeing, okay, is this still very helpful? If it's, and at some point it might not be, and it was, we're going to keep working on all this stuff, I would say, okay. So let's say, you know, a TENs machine, quite often, people that I work with are using tens machines, because it helps them to do something of value. That's it, that's what we're working for. But if they're saying I go to the physiotherapist or a particular physical health therapist, whatever, and they give me, let's say core exercises. That just for it, just rotate through their active therapies, right? These are hands off therapy, call exercises to strengthen my core.

Laura Rathbone (40:47):

And I do them. And I have worked with these people where they are doing them four or five times a day. And they're in pain when they do it. They're in pain after they do it, they're in pain the next day. And they've been doing it for months, some of them. And you're saying, well, actually, is that helpful? There's an active treatment. That's an active treatment in a way, that's the person doing it, but that is a passive approach to receiving therapy, right? Because they're not thinking and not enough. And don't feel like they're able to have the space for their own opinion on whether this is working for them. It hasn't been created in the therapeutic alliance. So, so that they're doing this in the hope that they get to the goal of the therapist that they're going to get, but they're not necessarily getting there, but they're still doing it cause they haven't the safety and the relationship hasn't been created. So that person can go back and say, actually, this isn't helping me. So we can say, okay, that's not helping. We can change. You don't need to do stuff that's not helping. If this is making your pain worse, then it's causing pain. Why are you doing it?

Karen Litzy (41:51):

Yeah. And it's so funny. I had that conversation a couple of weeks ago, the gentleman with chronic low back pain, it's been six months of low back pain. And the doctor said, we'll read this book and do these exercises. So he was doing press ups and press ups at an angle and press ups. And, and I said, well, how long have you been doing that? And he said, I've been doing for a couple months. I'm like, Oh, well, how does it feel? He's like really hurts when I do it. But you know, the doctor said to read the book and do what's in the book. So I'm just doing what's in the book. And I said the same thing. I'm like, well, there might be ways that we could alter this, or there might be other things that might be more helpful if you're doing this particular exercise.

Karen Litzy (42:38):

Exactly what you just said. Well, it hurts when I do it. It hurts more after I do it. And it hurts the next day more after. And I said, well, okay, let's explore this because I think there might be ways that we can make this work. And lo and behold, we found ways to make it work, but it's just, yeah, it's just that exact example of what you just said. And having the conversation was maybe a little uncomfortable at first, because this was something the doctor said to do. And so we had to do it.

Laura Rathbone (43:14):

Yeah. But I mean, that is a typical example where a clinician just has not invested in their communications strategy or their compassion for the person in front of them. They haven't even created a dialogue. They've just given somebody a book and said, your problem is so common that we've written a book on exactly how to get out of it. You just need to follow this. There is no dialogue that, and the thing is pain. Pain makes us very vulnerable, right? Pain creates a huge vulnerability in us. And we know that when we have pain, we are vulnerable and it's no different for the person in front of you. That's been living with it for years. They've just got more pain and had it longer, maybe feeling more vulnerable and more desperate to find a way out. And that's completely understandable. So shame on that clinician, because that is not okay.

Laura Rathbone (44:07):

We have got to invest in our dialogue abilities. We've got to commit to being good communicators and compassionate communicators and compassionate listeners. And, you know, really want to know about the human we're working with as opposed to dismissing their pain as something that a book can feel. And of course there are very helpful books out. There are helpful textbooks that have been written by very compassionate clinicians and some are better than others. And I'm not trying to say all self help tools are all bad because that's not, that's not the point here. The point here is that if there's no, there's no way, there's no space for the person who is living with pain to explore with you, the solutions that you're putting up, then, then it's very difficult for people to know what to do next. And it's very easy for them to feel like they're doing it wrong or that they're somehow not committed enough. So then they'll might do it twice as many times and more often and more days, and with more effort, because that's the only solution we've given them.

Karen Litzy (45:18):

Yeah. And then I think it also brings on for the patient sort of coming from my own experience is that, well, I can't even get this right? Like you failed yourself. You don't even know your own body. It takes you. I think it disembodies you even more than perhaps you already are out of protective purposes. And it just takes you further away from yourself and your person, if you will, because if you can't, you know, you read the book, you're doing it. The doctor said, you're doing what the therapist said, and you still can't get it right. Then you're just a failure. And it, again goes back to feeling hopeless. Like you said, like your mom felt like she didn't have any hope and she felt very hopeless. And I think these sort of faulty communications and inability to tune into what the patient is telling you leads to that feeling of hopelessness and failure from the patient point of view. And so I can totally see how using ACT as a framework and being able to acknowledge the person and what they're doing. And, are there some alternatives that can be used, maybe not now, but maybe in the future or where you are now and what can we do at this point? And it was working now, but let's keep in mind that there are some other things that we might be able to augment your program with.

Laura Rathbone (46:58):

Yeah. And I always say that brings me on to probably the next thing that really, I think, feel very, very passionate about. And there are many new ones to watch my Facebook page, but you know, this is, I think one of the big misunderstandings we have about integrating psychologically informed physiotherapy, right. Is that we still think that it's something we do to other people. And that's why I don't really like the term psychologically physiotherapy, because it's still, although I think it's the best one we've got right now. And I think that, you know, it's a lovely way of thinking about how we therapize people, but it still puts the workload and the part of our identity that is physiotherapists. It's still what we do when we put the uniform on or when we go into our clinical encounter.

Laura Rathbone (47:51):

And it's still something that we do as a thing to all the people. But, you know, if we think really and truly reflect on the idea of the biopsychosocial model and the hierarchy of natural systems, this idea that a human is embedded within their environment, then the clinician is a part of the external environment and the patient or the person that's chosen to work with us is a part of our external environment and has an influence on us. And we have an influence on them and we need the real richness with acceptance and commitment therapy is that it is something that we're thinking about, okay, what is happening in my present experience that I might be struggling with that might be coming up in me that might be having an influence on somebody else?

Laura Rathbone (48:45):

What is my reaction to that person's story or that person's behavior, or that person's diagnosis, right. You know, what's happening in me so that we can also remember that work with our own resistance and become aware, especially now become aware of our own privilege and how that might influence and take away from somebody else's privilege or equity or equality or justice or access. And this is something that we need to reflect on very, very deeply as clinicians working in an area like healthcare, where access is very, very important. And it's our role to make sure that we're delivering high quality care with open access. And so acceptance and commitment therapy is a way for us to also take that moment and be like, okay, well, what's going on in me here? How am I helping this person what's happening in my reactions and my emotions and my sense of self and is that always helpful? So if my goal is to deliver an open and evidence-based and compassionate approach to experiencing any resistance or challenges to doing that in this situation, and maybe I need to work with that.

Laura Rathbone (50:02):

I think that can be true. Across musculoskeletal health, when, you know, people see, you know, patients or people with pain coming in and they have persistent pain, and it's not going to get better in six sessions, three to six sessions, and we've all got those targets, right. And they're going to need more than 30 minutes. So we're going to have to explain to our manager why actually did more than 30 minutes. You know, all these sorts of things what's happening is our instinct to push them away to somewhere else, or to create departments where we, you know, where we don't accept people who have pain for more than three months, or, you know, then there are those departments out there that push the access away to somewhere else.

Laura Rathbone (50:49):

So there's a bottleneck in all the parts of our clinical approach. Actually, maybe we could just upscale a little bit and recognize that persistent pain is a very big part of our musculoskeletal population. And we all have a duty to be better at it.

 

Karen Litzy:

Yes, very well said. And like you said, especially in these times, so listen, Laura, I want to thank you for coming on, but before we wrap things up and get to a good, and now a nice announcement from you and what you're doing in regards to ACT, I'm going to ask you one more question that is knowing where you are now in your life and in your career, what advice would you give to yourself straight out of university?

Laura Rathbone (51:52):

Gosh yeah, I would say what I am learning is that I'm not always the right person at that moment. And sometimes my desire and urge to fix people quickly as well, and to do right the injustice of having pain and to really get rid of that pain as quickly as possible. Sometimes that has I think, taken away from the therapeutic potential in some environments and in some experiences. So, and also has just caused me in a lot of pain, you know, and we have to remember that we are humans in this, that we are not, clinicians are people that go home and try to, you know, keep going after hearing some very difficult stories of all the people and, you know, we're also not immune to when the people we work with don't get better in the way we want them to, you know, we take that on. Yes. One of the most important skills that I have been learning is to be more forgiving of myself.

Laura Rathbone (52:51):

And to remember that life is complicated and people are coming into our clinics with a whole lifetime of experiences that I am not aware of and not privileged to. And they are not aware of or privileged to mine and being slower, taking more time, being more gentle, not only with people who choose to work with me, but also with myself actually has brought me to a place where I am having a better relationship with my job. I'm getting better relationships with the people that I work with. And I just, yeah, I am able to sustain this work now for longer than I would have been, you know, eight years ago when I first started in particularly working with longterm pain, it was very hard for me and I went through my own version of a burnout when I was constantly finding, trying to find more information and be better and upskill, upskill, upskill. Yes. We need to upskill. Yes. We need to learn about these things, but we also need to find good supportive mentors and good environments that we can next explain and explore what we're going through and ask for help. If we're feeling very effected by what we're hearing every day, you know, good relationships with our colleagues, physiotherapists, occupational therapists, psychologists, social workers, help us to, you know, share our experiences and our load. And be more forgiving of that, I guess. I don't know if that's a good answer.

Karen Litzy (54:27):

That's an excellent answer. Are you kidding me? Fantastic. And now speaking of gaining skills in service of others, what do you have coming up? Cause I know you have like a course that you have put together. So can you talk about that and where people can find more information?

Laura Rathbone (54:52):

Yeah. So about six months ago, I started putting together and planning a two day course, right? Typical 15 hour, two day course, people would come to our room and we would do two days of ACT. And then, you know, the situation with COVID-19 and all of our lives changed, and that didn't seem like it was gonna make most sense. So it shifted into a sort of online collaborative learning and it's still, we're still figuring out how this is going to work, but instead it's going to be four sessions of three hours of contact and collaboration over four weeks. And then there's going to be like support and forums in between. And that will be going live hopefully at the end of July, if I can get the luck. But if people do want to come on a course with me, or they're interested in exploring ACT and they just got some questions, best thing they can do is go to my website for information for even better, because I'm basically always on social media, find me on Facebook or Twitter, whatever, flip me a DM.

Karen Litzy (56:03):

And now, so we'll have links to all of that under the show notes at podcast.healthywealthysmart.com, but can you just shout out your social media handles?

Laura Rathbone (56:17):

If I can remember them. @laurarathbone (twitter) @laurarathbonevanmeurs (facebook) @laura.paincoach (Insta) Yeah, that's more of a patient facing platform for me. So that's Laura.pain coach which is the title that I tend to prefer. So sort of working as a coach, as opposed to as under the strict title of physiotherapy yet. So that was, yeah, those are the three social medias I use the most.

Karen Litzy (57:02):

Awesome. Well, Laura, thank you so much. This is a great conversation. It's certainly got me thinking of the way that I work with my patients and my clients, and maybe how I need to do a little more introspective work and try and really check my biases, whether they're conscious or unconscious biases at the door and really see what I can do for the person at the moment and listen to them and see what I can facilitate for them. So thank you so much for coming on the podcast and sharing all of this information. Thank you.

Laura Rathbone (57:40):

Oh, no, you're welcome. There's lots of books and websites and patient information out there. Just want to give a shout out to Steven Hayes who really is responsible for the framework of acceptance and commitment therapy and the association for contextual and behavioral science, I think it is, but I'll make sure that you get linked with that and why there are you know, resources on there for people to learn about acceptance and commitment therapy, because you know, this work isn't being done, the research hasn't been done by me, it's been done by lots of other people. So I would like to just direct people to look that up as well.

Karen Litzy (58:21):

Awesome. Well, thank you so much for coming on and everyone, thank you so much for listening. Have a great couple of days and stay healthy, wealthy and smart.

 

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