At this point, many of us are aware of the impact of beliefs on the experience of pain, disability, and recovery. As pain science and psychologically-informed care have grown in stature and popularity, many of us are working with our patients to identify unhelpful beliefs and adopt more helpful (and potentially more accurate) beliefs.
Today, I want to talk about a fundamental belief. One belief that seems to be at the root of many, if not most, unhelpful beliefs that contribute to a sense of disempowerment in our patients.
In this article, we’ll explore:
*If you're expecting a lot of Lord of The Rings metaphors, I'm really sorry to disappoint but I haven't actually read the books or seen the movies. If this news is a day-ruiner, feel free to throw me a mad face in the comments.
Why Beliefs Matter
It’s well established that psychological factors such as pain-related fear, psychological distress, and self-efficacy play an important role in the development of pain and disability, as well as recovery (1,2,3).
And we know that many psychosocial factors appear to be interrelated and overlapping. For example, beliefs about the cause of back pain and the expected outcome may contribute to pain-related emotional distress and fear (1).
There are different definitions for beliefs based on the discipline. For our purposes, we can think of beliefs as generalizations that our minds form based on our experiences and our interpretation of those experiences.
They form our conceptual understanding of the world and are therefore always present, regardless of our awareness of them. For example, you may have never thought much about it, but you likely hold the belief that the sun will rise tomorrow.
We know that beliefs have been shown to play an important role in the relative success of our patients (1). But this is not just the case for our patients’ beliefs, this is true for our beliefs as well. Our beliefs have been shown to influence the beliefs of our patients, for better or for worse (1).
In this way, we could say that beliefs are contagious, especially in relation to people we respect and trust.
So what kind of beliefs are important? Do some beliefs supersede others?
Exploring Beliefs & Their Roots
I used to think that the most unhelpful belief was the belief that pain can be equated to tissue damage.
It makes sense— believing that one’s body is being damaged anytime they feel pain is an extremely disempowering and fear-provoking way to live, especially for someone with longstanding or persistent pain. And one can see how from this belief, many other unhelpful beliefs could stem.
I went to great lengths to attempt to help people see things another way. Trying to get the message across that pain is more closely related to the body’s (including the brain) perception of danger vs. injury or damage.
But this is a very difficult concept to get across to people, partially because it challenges the commonly-held western conception that the mind and body are separate.
And I’ve realized that there’s something lurking under the surface of this belief. An even deeper belief.
Let’s look at some common unhelpful beliefs and see what we find lurking in the depths…
Common Unhelpful Beliefs (CUBs):
CUB #1: Pain attributed to pathoanatomy
This might come out by a person saying something like:
“This is from an old disc herniation.”
“My knee is bone on bone.”
Inherent in this belief is that pain is equatable to injury or damage.
But consider this…
Someone can believe that their anatomy is the sole cause of their pain, BUT if they believe that their body has the capacity to adapt and the drive to heal, they could very well feel empowered nonetheless.
If, on the other hand, they believe that their anatomy is the sole cause of their pain, AND they believe that their body is fragile and prone to break down, they will surely feel disempowered.
CUB #2: Pain = Damage, Pain = Injury
Now let’s look directly at the former bane of my educational attempts: that pain is equatable to tissue damage or injury.
If someone believes that whenever they feel pain they’re injuring themselves, BUT they believe that their body has the capacity to adapt and heal, again they could actually not be disempowered by this belief (even though it’s not entirely accurate as far as we understand).
But if someone believes that whenever they feel pain they’re injuring themselves or damaging their body AND they believe that their body is fragile and prone to break down, they will definitely feel disempowered.
CUB #3: There’s nothing that can be done
Another common belief is that nothing can be done, except maybe surgery, to ‘fix’ the problem. This belief is predicated on the idea that the body is prone to break down.
But this one is interesting because there’s also some cognitive dissonance here:
On one hand, the person believes that the body changes
But on the other hand, they don’t seem to believe that the body can change for the better, only for the worse
Another fallacy here is the belief that the future is known. And of course, nobody knows what’s going to happen in the future.
CUB #4: It will only get worse
Similar to the previous belief, this belief is predicated on the deeper belief that the body is prone to break down and shares the same fallacy— the belief that the future is known.
So it would appear that what’s often lurking in the depths of many common unhelpful beliefs—including the belief that pain can be equated to tissue damage or injury—is the deeper belief that the body is fragile and prone to break down.
From this root belief, many other unhelpful beliefs seem to sprout & flourish, forming a belief bush (technical term).
The (other) Problem With Body Fragility Beliefs
Aside from the inherently disempowering nature of body fragility beliefs that we’ve explored thus far, there’s another massive downside to this belief: Non-commitment.
If someone believes that the body is fragile and prone to break down, what can physical therapy even do for them?
(Orthopedic) physical therapy operates largely under the adaptability of the human organism and its drive for safety and balance.
If someone doesn’t believe that they possess the capacity to change for the better, the best they could hope for from physical therapy is the slowing or prevention of worsening.
Rightfully so, this leaves many people in a state of non-commitment. Because to commit to a process—any process—we have to believe that there is a possibility of success. If our patients feel only a marginal possibility of success, they will likely commit only a marginal amount to the process. Which can create a self-fulfilling prophecy
The reality is, there’s truly only one way to find out whether someone can improve— we have to try.
So our task becomes to help our patients see another way. A way that includes the possibility of change for the better. The more someone believes that change is possible, the more committed they will be, and the more we can truly explore the extent to which they can improve.
Exploring Another Way
To truly work with our patients, we have to take an explorative approach.
If I come in with the intention to change someone’s beliefs, I’m starting off in a stance that I know what’s best for them. This is not a good place to start. Not only is this terrible for rapport, but it’s also not correct.
Guiding people to explore another way of seeing their bodies is a complex process, a process that begins with our own beliefs.
“There is strong evidence that patient beliefs about back pain are associated with the beliefs of the clinician with whom they have consulted and moderate evidence that high levels of fear-avoidance beliefs in clinicians are associated with high levels of fear-avoidance beliefs in their patients (1).”
What Do YOU Believe?
So the real place to start—if we want to help our patients learn to trust their bodies—is asking ourselves, “What do I believe?”
The extent to which I believe the body is fragile is the extent to which that will come out when I’m working with patients. It will come out in my language, in my advice, in my diagnostic procedures, in my explanatory models, and in my management recommendations.
There’s nowhere to hide. We’re more perceptive than we’re often aware of. It doesn’t matter how many articles we read, courses we take, or podcast episodes we listen to, if we don’t believe what we’re saying to people, they will pick up on it, and what we do beileve will come out in one way or another.
This is something to explore and reflect on. No doubt you’re doing it already, and no doubt it will continue to evolve over the course of your career.
Some ways of exploring this are:
Paying attention to how you feel as you speak with your patients. Do you feel that you’re speaking the truth, or are you trying to prove a point?
Paying attention to how you deal with your own aches and pains. What thoughts, feelings, emotions do you notice in relation to your own pain? What actions do you take to manage pain when it arises? This is often quite telling
I’ll tell you where I land these days in relation to the body. If you’re not interested, feel free to scroll on past this section. No worries.
The body changes. It changes as we age. It changes based on how we use it, based on the fuel we give it, based on things that happen to it. It changes based on our habits, our lifestyle, our stress, our moods, our thoughts, our beliefs, our emotions, and more. Some of these factors are in our control, some aren’t. And just as the body can change in a direction that we don’t want, it can also change in a direction that we do want.
In fact, I believe the body is always striving for safety & balance. This is true for all living organisms, they have an innate drive for homeostasis and the capacity to change based on the conditions. We are no exception.
The bottom line is that we don’t know the extent to which our patients can change, but there’s literally only one way to find out.
So the question for our patients becomes: How far are you willing to go to see what your body can do?
Those are my beliefs. You might feel similar, you might feel different. The important piece is for you to get clear on what it is that you believe so that you can be aware of how you might be influencing your patients— consciously or unconsciously.
How can we work with our patients’ beliefs?
There are many methods of working with people’s beliefs. Education, counseling, demonstration, modeling, and more.
Let’s talk through these in that order
1. Education & Counseling
This is probably what most of us think of when we consider how to work with people’s beliefs.
I can’t talk about beliefs without first discussing ethics. I personally believe that it’s my job as a physical therapist to work with people, to fill in any gaps in knowledge (with permission), to guide them at most, and never to dictate how they think, feel, or behave. I often come back to the universal saying in psychology, that the only person I can change is myself.
For more on this, check out my episode on Law III of the Four Laws of Quality Care.
The ethical side of education and counseling, I believe, lies in helping people sort out any cognitive dissonance that might be present.
For example, if through discussion it comes out that a patient of mine believes that nothing can be done, and their knee pain will only get worse,
It’s perfectly ethical for me to point out that the future is uncertain, or to ask them if they’re 100% certain that it will get worse
It’s also reasonable for me to explore with them the logic of how the body can have the capacity to change, but only in one direction (worsening)
Or, I could explore with them why it is they decided to come to physical therapy if they don’t believe that things can change
Can you see how all of these things are simply shedding light on the dissonance that seems to be within this person? This is a far cry from trying to talk someone out of their beliefs or imposing my beliefs onto them.
Another way of working with beliefs is through demonstration. If we can show people another way—literally—this can be a tremendously powerful force for shifting beliefs.
Taking the same example from before—the person with knee pain—if we can show this person that their knee pain is modifiable, it can drastically alter what they believe about their body and their prognosis.
This could be done through symptom modification procedures like manual therapy or movement modification, or it could be done through exercise and graded activity.
There is one absolute requirement to this process though— measurement. Because to truly show somebody something, they need evidence. This looks like using a test-retest model to detect within-session changes, as well as collecting other measures to detect between-session changes.
Within-session, we could subjectively measure the person’s pain with a functional task and/or objectively measure their knee ROM. We then perform an intervention and test again. If changes are made, this can shed some light on the possibility of change.
We could also have them track their walking tolerance during their daily walks to see how it changes over time.
All these are ways of demonstrating the innate adaptability and healing capacity of the human body.
This is the principle of being the living example of what you’re saying. Living your message.
This is the step after figuring out what you believe— it’s doing yourself what you recommend that others do. Living in accordance with your own beliefs.
If I’m telling someone that the body is strong and resilient, but I brace my core to pick a piece of paper off the floor, what message am I sending?
If I talk about the body’s capacity for change, but I’m not investigating the ways that the person is adapting to our interventions, will the message get across?
If I talk about the importance of getting enough sleep but I’m not getting enough sleep myself, it’s empty advice.
If I’m telling my patient how important exercise is, but I’m not following my own recommendations, it’s not going to land as much.
If I’m advocating for the patient to look broadly at their life and explore some of the factors that might contribute to their pain. It might help if I share some of the factors that influence my own pain.
If I’m advocating for the patient to challenge themselves, face their fears. It might help if I confront some fears in my own life, whatever they may be.
Not only can sharing some aspects of my life with people build mutual trust but doing this also helps us know where our patients are coming from. If I challenge myself on a regular basis, I know how fucking hard and scary it can be. I also know how sweet the reward is on the other side.
Much of this concept can be simplified to say: Take your own advice. Live in accordance with your own beliefs and you won’t need to work as hard to show people your side of the story, it will simply come through you.
Working with people’s beliefs is no simple process. It poses ethical and practical challenges. By helping to resolve cognitive dissonance, demonstrating the innate adaptability of the human body, and being the living embodiment of our message, we might be able to help guide people toward rebuilding trust in their bodies again.
Sidebar: Where does pain science fit into all this?
We’ve bumped up against pain science a lot in this episode so I want to address this a bit more directly.
I see pain science education as the step after addressing this deeper belief. If we attempt to tell or show people that pain is not equatable to tissue damage, but we don’t address this deeper belief, that the body is fragile and lacks the capacity to adapt, we likely won’t get very far.
The requisite first step seems to be the mutual understanding that change is possible, and a certain level of committment to the process of exploring the extent to which things can change for the better. Once the person is open to the idea that the body can change (though we don’t know by how much) and has some level of commitment to the process, pain science can be sprinkled in and will likely be much better received.
That’s my belief at least…
Beliefs matter. They play an important role in the development of pain and disability, as well as recovery.
Many of the common unhelpful beliefs that our patients hold can be traced back to a root belief that the body is fragile and prone to break down. This can result in disempowerment and a lack of commitment to the process of care.
Beliefs are contagious. Our beliefs have been shown to influence the beliefs of our patients, for better or for worse. Investigating our own beliefs is, therefore, an essential first step to working with our patients’ beliefs.
Exploring another way with our patients can look like:
Investigating cognitive dissonance that comes out
Showing the person that change is possible
Being the living example of our own beliefs
Once the person is open to the notion that things can change and has some level of commitment to the process, pain science principles can be sprinkled in and will likely be much better received.
Thanks for reading.
Darlow, B. (2016). Beliefs about back pain: the confluence of client, clinician and community. International Journal of Osteopathic Medicine, 20, 53-61.
Darlow, B., Dean, S., Perry, M., Mathieson, F., Baxter, G. D., & Dowell, A. (2015). Easy to harm, hard to heal: patient views about the back. Spine, 40(11), 842-850.
Bunzli, S., Smith, A., Schütze, R., Lin, I., & O'Sullivan, P. (2017). Making sense of low back pain and pain-related fear. journal of orthopaedic & sports physical therapy, 47(9), 628-636.