In this episode of The ABMP Podcast, Doug Nelson speaks about invalidation with clients, connection and the shared human condition, and the difference between validation and reassurance.
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0:02:02.2 Doug Nelson: Hello everyone. This is Doug Nelson, licensed massage therapist and longtime author of the Table Lessons column for ABMP's Massage and Body Work Magazine. And you are listening to the ABMP podcast, a podcast that speaks to the massage and body work community. I'm recording this actually on a Saturday, I just came from the clinic and was inspired to do this just because if I'm not teaching on a Saturday and gone for the weekend, I'm probably in the clinic doing what I love to do, which is seeing people. And today it happened again, someone that I saw at some point in tears after we were doing some work, she looked at me and said, "I'm just so happy someone believes me and believes that I hurt." What a statement. Wow! And so that is the subject of this podcast, which is invalidation. And I bet this is true for you as well, that countless times you've sat across from people who have felt invalidated by, it can be friends and family, it can be healthcare providers, that somehow people just don't believe them.
0:03:16.7 DN: Years ago when I was writing "The Mystery of Pain" book, this was a theme that kept coming up over and over again when I was diving into the science of pain, but also interviewing people in chronic pain. And that theme of invalidation seemed to resurface again and again, and I think that's important. It happens in many different levels. It happens personally, it happens professionally. So I thought we would take just a little bit of time to explore that. And it's a subject about... Which as I was driving home, I was thinking about all the different Table Lessons columns that have really touched on this. Just a couple of them, I think it was probably a couple of years ago, this woman called the clinic and she had said that she had seen other people and people on my staff and nobody really addressed what she needed. I was talking to her on the phone and asking her questions, I was not clear about what her needs were. And I told my front desk, I personally need to see this person because even talking to her, I still don't understand what she needs. And when she came in and sat down and I sat across from her, in short order she described the loss of her husband who had passed away just about a year earlier and how devastating that was.
0:04:41.1 DN: At that moment, connecting with her, looking her right in the eye and saying, "I know how much I love my wife and I cannot imagine how devastating that must be for you." And in that moment, I could tell that there was a connection. And honestly, the work that I did with her was nothing special at all but she felt like somebody actually heard her and related to her. That was a remarkable event to me, a statement of it's about connection and it's about the human condition, the shared condition. We are human beings first and therapists second. Another one that... Another Table Lessons that I wrote about, I can see this person 'cause that was also on a Saturday and I had come in to see this person who presented with some really difficult things. She was lying on her side, she had rib pain, and at some point when I was treating, I think it was the external oblique, I think whatever it was, she blurted out, "I knew it." And yeah, I'm thinking, "What the heck? There's a whole dialogue going in here that I am not privy to." And when I finally... When I asked her, "What is going on? What are you saying? What does this mean?"
0:06:06.1 DN: She described how she had had this rib pain for an extended period of time, and at some point people just didn't believe her anymore. And in fact, the last physician had given her a book, "Psychosomatic Pain." And honestly, here's a skinny Norwegian who comes along and presses and can replicate her pain. And once that happened, she knew, "Yes, this is real." And we are so lucky in that way to use touch as a form of validation, that we get to do that. That is a really great asset to the work that we do that honestly in other professions, they don't always have that. You'd have to know something about the methodology of this or have some trust in the person to make that leap. And you can name a lot of professions that are like this. For us personally, in our field, someone comes in with some symptom, we actually get to access the tissue and in many cases replicate their symptoms. And this becomes an issue. And students have always asked me, "Well, how do you educate your patients?"
0:07:21.7 DN: Well, there's not a lot of education that needs to happen at that point, because you press, they experience, they re-experience their symptoms, their brain figures out really quickly that whatever that is is connected to what I experienced. There must be a relationship between those two things and therefore it's actually validating. So we are very lucky to have that as an asset in our profession. There are actually a few types of invalidation, perhaps maybe five, that I can think of. Not being believed is one of them, and that's certainly the one that I talked about earlier. And we see this quite often. And I think in our profession this comes up quite a bit because a lot of what we deal with is called nociplastic pain.
0:08:15.1 DN: Nociplastic pain is pain that is not visible through imaging or other technologies. We're so used to the idea of whatever you experience can be imaged, and if it can be imaged, therefore it can be seen. So that old model was anything that can be seen, can be identified and therefore eliminated and the pain will go away. It's a lovely model. It's a terrible reality, but it's a lovely model. Turns out a lot of the pain that people experience, there is nothing to see on an image, but that doesn't mean that it doesn't exist.
0:08:57.2 DN: And as a healthcare system, we really struggle with this and it's an experience that those of us in this field who've done it for a long time, we know all too well. And so it complicates things, but it's the genre that we deal with. And there have been long histories, long histories of different conditions that over time, at first we didn't know why people experienced these things, and then we invalidated those people and only to find out later it's the, "Oh, there's actually a reason." And then the new syndrome comes up and suddenly those people have somewhat of a validated point, although it didn't really help them at the time. So yeah, if you dive into the history of this, it's not pretty actually.
0:09:45.6 DN: And then another form of invalidation is lack of compassion. People can acknowledge what you feel, but you can just tell they're not connecting on a very deep personal way. And I think certainly it's a lot of people's experience with healthcare that compassion sometimes is pushed to the side just a little bit. And then the other thing is just a lack of pain awareness and understanding. Like I saw... The person I saw today was like, "Well, how many people know about this stuff and why don't other people... " She said that she had seen, she told me 23 different medical professionals, but nobody had examined her soft tissue with this kind of thoroughness and precision. And she was like, "I don't understand how this is not more known." And I lecture at the medical school, I have done this for many years, and part of that lack awareness and understanding is just the amount of time that in, at least the medical school that I haven't spoken at, there just isn't a ton of education on musculoskeletal problems.
0:11:01.1 DN: The problem with that is it's the second most common reason that people seek medical care, so if the provider doesn't fully understand the potential ramifications of this, yeah, then the symptoms that someone presents are not gonna make a lot of sense. And as I told this person today, our job really is that the client comes in with a plethora of what they think to be random symptoms that is confusing, and my job in this case is to take the randomness out of it; to say, "There could be a model of understanding where all of this makes sense," and then organize it into a model, then design a treatment program based on that model. And then it's all about whether you create results or not. So models are easy in some ways, results are harder. And that's why I absolutely love being in the clinic, because the clinic will humble you. I know there are people who think I should spend less time in the clinic and more time with other things in education stuff, and the clinic is my laboratory. It just fuels me and humbles me. And I think it's a good thing when I'm teaching, when people ask really complicated questions, I can't give them a really simple answer because I know what it's like to be in the clinic and struggling and dealing with very difficult things. Things are hard because they're hard.
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0:13:49.0 DN: Another invalidation possibility is the feeling stigmatized, and there are certainly a number of communities that have felt that. Certainly with women and pain and minority communities, that's a really sad history. And then I think at some point too, especially when people don't have an explanation for this, healthcare providers, it's likely that the person starts invalidating their own experience like, "Am I really feeling this or is this just something that has no explanation?" And then you just kind of put it on yourself. And that is really, really difficult. And I wanna go back to the touch as validation thing in terms of replication of symptoms, which is wonderful. But one of the other things that... How many times have people, clients said to you, "Does that feel tight to you?"
0:14:49.0 DN: I know you could get really technical and whatever with the answer, but really that's not what they're asking. What the client is saying is, "Man, that's really sensitive." Like, "Wow! Who put that there?" And what they're looking for from you is some validation, that you can feel in a way what they experience. As I tell clients, I know what I feel, but I do not know what you experience. Let me just make a suggestion to you, which is when you get a question like that, that seems like, "Ugh, maybe I shouldn't educate them," don't do that. Just my retort to them is, "Why? Is that sensitive?" And then you get the, "Sensitive, are you kidding?" It's like that's the form of validation that they want. So sometimes the questions are a little bit of a veiled thing because they don't really know how to phrase it in a way. So that's really important.
0:15:44.9 DN: Here's another piece of practice management stuff for validation that I think is really important, and I've certainly communicated this to my clinic staff, which is touch where they present. I'll give you an example of this. A while ago we had this woman who called the clinic and I ended up talking to her because she was unhappy with her session. And she had come for plantar pain and my therapist being very smart, very good, she went right to the person's calves and did some great work. Then this woman calls me 10 days later and is complaining about her session. What she complained about is that my therapist spent like zero time on her feet, but spent the whole time working on her calves. Here's the wild thing, in the conversation, just a little gentle query, turns out her symptoms were better, but she was still unhappy. How wild is that?
0:16:45.2 DN: If you come in, you would think the goal is that I want, yes, a cessation of symptoms. Well, actually she got that, but that's not the whole story. What she wanted was someone to touch where she hurt in her foot, to say in a way, "I get you. I understand you." Even if someone comes in and there's a situation like that, where like someone has a occipital discomfort and you think, "Oh, yeah. That's probably coming from... " Don't get cute. Start first with wherever they're experiencing their symptoms as a way to say, "I hear you. I get you." And I think sometimes when I'm teaching people ask about warming up the tissue and I tend to go right there. I tend to put my finger right on the discomfort as quickly as possible.
0:17:41.7 DN: So that communicates to this person, "I know what I'm doing, I know where you hurt." And now the question is, "What's the best strategy to deal with it?" But it is not, "Where is this thing?" I can locate it and absolutely pinpoint it. That's really important so that that nervous system knows, "Whoa. Okay, that guy has nailed it." Again, how you deal with that, and in many cases a more indirect approach is a better treatment thing, but once you locked onto the, "Yes, I know where it is. Now, let's talk about what's the best way to deal with it." When you go back and recheck it over a few minutes and you find it less, now the person is gonna realize, "Oh my goodness. There's a whole system that creates this." And I think that's really, really important. And I've had therapists who are really smart and a little too smart actually, because they've gone to that second or third layer out and thinking, "Well, this is really gonna make a difference." And it's only helpful if the client is actually following you during that process. There's a saying about being ahead of the curve. [chuckle] Another way to phrase that is, you're so far ahead of the curve, you're off the road. 'Cause you have to take the client with you in the vehicle in that sense, if we're to use that metaphor. So I think it's really important that you identify that.
0:19:07.8 DN: And again, when I speak at the med school, I'm always telling these fourth years as they go into clinical practice, please, please touch your patients. How many of us have had clients come in and they tell us that no one's ever touched this. I remember a Table Lessons from years ago where that's exactly what this person said, that no one ever touched it. For somebody who's had pain for years, how is that even possible? There are a whole bunch of really interesting studies on validation in the healthcare system and I won't go into all the details with that, but I wanna make one distinction really between validation and reassurance. Today, this person, I validated her pain. We were able to replicate the symptoms. I explained the model of understanding, but it's not like, "Oh, I'm sure this is gonna be great and... " Have you ever had people do that to you, where it's like they're trying to be reassuring and it's just annoying because you can tell they're soft pedaling this thing. And if she's seen, and in this case 20 some other people, they all felt pretty confident they were gonna have results. I was just laying it out there like, "We're gonna follow this model." And she was like, "Oh, that's great."
0:20:28.6 DN: I was like, "Well, we don't actually know how great it is. We're gonna follow the model, if in three sessions, maybe four, we're not making any progress, guess what, we'll start over again." But it's about relentlessly pursuing results. Clever models are interesting, but I'm interested in one thing which is results, so I cannot guarantee you in any way that this is correct. Everything seems good right now, but understand... And she had just gotten a PhD, so she gets this. Remember Einstein said, "We wouldn't call it research if we actually knew what we were doing." Well, in the clinic it's the same way. You construct something, but now you have to... The rubber has to hit the road. And that is about results. If we step back just a little bit, I wanna do it from a personal level as well because I think it will... It applies across the board both personally and professionally.
0:21:31.2 DN: And here's a couple of examples. Have you ever had people who say things like, "Oh, I'm sure everything will turn out just fine." Or have you ever said... Like I might say to somebody, "Oh my goodness, I have to record this podcast for ABMP and I've to get it done by such and such." And then someone might say, "Oh, it'll be fine. You always get stuff done." It's like, "Well, yeah, you know how it gets done? I work my butt off and that's how it gets done." It's not helpful, it's actually, again, kind of irritating. And what's irritating about it is, you know what it takes to get it done and it's a lot of hard work. And so when people say, "Oh, I've heard you say that before and it always turns out fine."
0:22:11.1 DN: "Yes, 'cause I always end up rising to the occasion and doing whatever I need to do to finish whatever I'm doing." That's one. And when people say stuff like that, it's frustrating. And another one can be the kind of one-upmanship. I have someone I know who, if I say my big toe hurts, this person will say, "Oh, man. Two weeks ago, mine was... " And then whatever you say, the comeback will be, "Oh, that's nothing 'cause... " And then you think, "Why am I even saying anything?" And then you'll question, "Why am I saying this?" Sometimes you just wanna vent a little bit, say, "Gosh, I'm really tired." You don't need to hear from the other person, "Oh, you think you're tired?" And or that personal thing, when I was talking about the person earlier who lost her husband, when you personalize it, that's never a good idea.
0:23:06.4 DN: Stuff like, "Oh, I know how you feel. Actually no, you don't. So there's something about this thing of, "No, I'm sorry. You don't know all the circumstances of my life, and so I sort of doubt that you feel that." And then there are the fixers, whatever you say, then they come back with an answer. Some things don't need an answer. If people ask for it, good, otherwise, when people say, "Gosh, I'm just so stressed about this paper I have to write." It's like, "Gosh. Yeah, I know. That must be really difficult to be under the gun yet again," instead of, "Well, you know what works for me is I do the... " It's like, "Well, great. That's really not why I brought that up." And so I think we need to be a little sensitive about those kinds of situations.
0:23:55.4 DN: So the first thing that I would say is the most important thing is to validate peoples' emotion. If say they say they're frustrated, if they say they're tired, if they say whatever it is, just validate the emotion that they're feeling, and in that people will feel heard. Somatically, in our profession, we get to do that through our hands and we get to validate their inner... Their somatic experience. And that alone is an incredibly powerful thing for the nervous system. And again, what a privilege it is for us to be able to do that, both on the personal level and also the somatic level. It is that sense of the connection, the human connection, the human spirit, it's the, "I hear you. I see you. I am with you." Few forces in the world are more powerful than that, and it's one that we have the privilege of operating from every day in the clinic. One of the many blessings of being in this field of massage therapy. Thank you all for the wonderful work that you do.
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