Monday, February 27, 2017

Symptom Modification: The Next Question

I’ve finally been lulled from my blogging hibernation! I first started sniffing the air when a discussion broke out between two of my favorite PT thinkers, Adam Meakins and Greg Lehman, regarding symptom modification.

Adam wrote this post, to which Greg provided a rebuttal and Adam a response. Both Greg and Adam agree that symptom modification is not necessary for recovery, but may be sufficient to guide practice. Greg and Adam demonstrate what a fierce debate can accomplish when the parties involved don’t get their noses bent out of shape over disagreements and at the conclusion of their discussion there appears to be agreement that symptom modification is 1) not necessary and therefore doesn’t dictate practice but 2) MAY provide a guide for practice. This goes to the point that I like to make that we often confuse opportunities for change with specific dysfunctions needing correcting.

The next question that I think is relevant is this: Under what (if any) conditions is symptom modification defensible?

Under what (if any) conditions is symptom modification defensible?


To answer this, let’s first look at the concept of belief disconfirmation.

Several of the speakers at this year’s San Diego Pain Summit spoke of disconfirming beliefs and even behavioral experiments got some air time , which made me very happy as these are two of my favorite topics! The idea behind belief disconfirmation is that the patient has a belief about the nature of the problem, and that belief stands in the way of recovery. It could be something like “hurt equals harm.” A belief disconfirmation is when this “maladaptive” belief is refuted in some manner, such as through education (cognitive approaches that aim to update the information that the beliefs are based on) and/or experiences (behavioral approaches that aim to demonstrate that the belief was incorrect). A modification of symptoms MAY be able to serve in this role of belief disconfirmation, which is potentially great! But, it is also obvious that there are scenarios where a modification of symptoms may only serve to strengthen the maladaptive belief! “I wasn’t safe to move until the pain was better. So, pain does equal damage!” or “When the therapist popped my back I felt better. A bone must have been out of place after all!” So, I don’t know that beliefs are always a good target to aim for. Beliefs tend to be tough to pin down. We (all humans) tend to actively seek out information that confirms our existing beliefs and ignore evidence to the contrary (confirmation bias) or we alter the incoming information to match our beliefs. So, beliefs tend to be pliable, slippery, and bias filled and often make life a living hell for a anyone trying to change them. Don’t get me wrong. I think when belief disconfirmation can be achieved it is of huge benefit. I’m saying that it is a difficult target because of our human tendencies toward bias. In fact, what often happens when we are shown evidence that contradicts our beliefs is that we actually entrench even further in the belief! This is known as the backfire effect. If you need to see this for yourself, just open up your preferred facebooking machine and go try to change someone’s political beliefs. Good luck!

So, what can we do? Enter expectancy violation. Sandy Hilton and I have gone on and on about this in the past year on our podcast. This is the piece of the puzzle that really ties things together and gives us a path around this moving target of belief. It is very similar to the concept of belief disconfirmation with an important distinction: prediction. It pins down belief to something specific, making it less pliable and slippery to escape the disconfirmation. For example, the belief “hurt equals harm” may lead to the expectation of “I can’t bend forward without damaging my back.” Now, this is different. This gives us a specific action “bending forward” with a specific prediction, “back damage.” And if we prompt them to more specifically predict what “damage” would look like, we might get to something like “more pain, less mobility, less strength, etc.” Now in this scenario it becomes clear that a symptom modification may become very important IF it refutes the prediction. In other words, if they can be shown that they CAN bend forward, and were able to do so without the specific outcomes that THEY predicted, then they’ve refuted their own prediction. The specificity of the prediction reduces its vulnerability to bias, its slipperiness. When both the prediction AND the refutation come from the patient, so they own it, it should make the backfire effect less likely. Now they are not looking for confirmation. They are looking for an explanation.

So, getting back our question: Under what  conditions (if any) is symptom modification defensible? In my view, symptom modification is defensible based upon 2 conditions: 1) it serves to refute a specific and relevant expectation and 2) the patient assigns the source of the refutation to themselves.

Symptom modification for its own sake doesn’t likely move the needle much, if at all, and as was described above could actually strengthen a maladaptive belief. Symptom modification to the degree that it demonstrates an ability of the condition to change may have some value but this too may be limited as the change is usually fleeting and may establish the treatment as a safety signal, where the patient attributes the change to something external to themselves, and/or foster some level of dependency. However, if the symptom modification refutes a specific prediction, then it can be very useful in my view. To be defensible, it also needs to support or build self efficacy, and be focused on a relevant and valued goal of the patient. I have many more thoughts on how this shift in thinking simplifies how we approach building the therapeutic interaction and I will spell some of these thoughts out in the next few posts.

Stay tuned!