LIVE from the WCPT Conference in Geneva, Switzerland, I welcome Daniel Board on the show to discuss torture-survivors’ experiences of healthcare services for pain. Daniel Board is a Specialist Pain Physiotherapist working in a pain management clinic at Chelsea and Westminster Hospital in London, UK. Clinically, he helps people with a variety of persistent pain conditions and has a special interest in refugee healthcare.
In this episode, we discuss:
-Torture-survivors’ experiences of healthcare services for pain
-The importance of the patient-clinician relationship and communication skills
-How to avoid burnout when servicing this patient population
-And so much more!
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For more information on Daniel:
Daniel Board is a Specialist Pain Physiotherapist working in a pain management clinic at Chelsea and Westminster Hospital in London, UK. Clinically, he helps people with a variety of persistent pain conditions and has a special interest in refugee healthcare. Daniel is also an early career researcher and recently conducted a qualitative study investigating torture-survivors’ experiences of healthcare services for pain.
Read the full transcript below:
Karen Litzy: 00:01 Hey everybody, I am coming to you live from WCPT in Geneva, Switzerland. And I have the pleasure today of interviewing Daniel Board. Daniel’s a physio therapist in the United Kingdom and he specializes in persistent pain. So Daniel, welcome to the podcast. And today you had a really interesting platform. So I want you to kind of give the listeners a little insight into what your platform was, because like I said, you are specializing in persistent pain, but you really have a very unique perspective.
Daniel Board: 00:35 Yeah. So my background is in working with people with persistent pain problems. And part of that is that I’m lucky enough to work in a specialist clinic for torture survivors at Chelsea and Westminster Hospital in the UK. The platform presentation I did today was presenting the findings of a research study that we did last year, looking at the experience of persistent pain in survivors of torture survivors are kind of an underrecognized group. They have a variety of psychological, physical, and social, kind of consequences and burden as a result of torture. For example, persistent pain rates succeed. 80% inspires of torture. Rates of PTSD and depression exceed 30%. Issues aren’t just standalone. Many certainly the torture survivors that we encounter are living in a country of excile and there are also lots of problems associated with that, such as seeking asylum, lack of social support, and also obviously the language barriers, and kind of what they’re not necessarily knowing what their rights are with regard to accessing services within the UK. So that’s the population.
Karen Litzy: 01:49 And what did your study specifically look at that you presented today?
Daniel Board: 01:54 So what we looked at from the evidence base is very limited. There was a Cochrane review last year that looked at interventions for managing pain in torture survivors and they find that there was no evidence to refute or support any intervention currently for managing persistent pain. Clinically, we see, as I said, quite a complex population and typically outcomes from treatment aren’t great. We also find it quite difficult to engage them within our services. We have high sort of failed attendance rates and that really affects their ability to access and benefit from healthcare. So the study that we looked at or the study that we did was a study looking at what’s torture survivors experiences of pain services in the UK is like so often, torture survivors that generally the first place they’d go to is that GP with a pain problem.
Daniel Board: 02:48 But they would also, the participants in our study, had seen GPs, they’d seen physiotherapist, pharmacist, they’d been referred to trauma orthopedics, cardiology, rheumatology, and that in itself posed a number of issues. So one of the first things we find was actually there was a big confusion over or a lot of confusion from the survivors of torture perspective over what their diagnosis was. So because they’d seen lots of different health care professionals, they’re often confused. So for example, one of the quotes in our study was, ‘One says you have fibromyalgia, one said you had PTSD and another one said a slipped disc.’ So all of these things, they don’t necessarily mean a lot to the patient and it can often leave them confused. So it was the first thing that we found.
Karen Litzy: 03:34 And with the finding like that and like the confusion of the patient, is that a reason that may be why they’re not seeking out physical therapy or maybe why they drop off?
Daniel Board: 03:46 I think to be honest, I think there’s a number of reasons why they might not engage very well. I think there’s a couple of issues with diagnosis and let’s maybe start with that. One of the things we noticed in the study was a really overly biomedical approach to diagnosing and treating pain, which isn’t isolated to torture survivors. It’s widespread, but certainly with this group that was relevant. So participants receiving diagnoses like degenerative disc disease or disc derangement. These were things that were noted in our study. And even if they didn’t fit necessarily with the participants picture of pain, so they might have had widespread pain or pain that didn’t fit that specific diagnoses. That does a couple of things. First of all, providing a diagnosis, which doesn’t necessarily fit the clinical picture.
Daniel Board: 04:38 It takes away, I think, ownership of being able to do anything about it. So by saying you’ve got disk to arrangement that’s going to instill fear, that’s going to take away any kind of ability that they might perceive they have to change that situation. So that was one of the things with diagnosis. The other important thing we find was that there was a distinct lack of recognition of torture experience when diagnosing pain. So if torture was recognized often it was done. So the word that came up quite a lot in the study was that participants had a biopsychosocial overlay, which in itself is a pretty ambiguous term. And there was a real lack of recognition of the affective and cognitive components of a pain experience and how torture experience might influence that within a pain experience. So I think that would affect how do they engage with services because I think it takes away some of the ownership by providing that kind of diagnosis.
Daniel Board: 05:31 I think the other thing is that it’s not as simple as there’s not one thing that is the problem with us engaging this population. Rates of PTSD and depression are very high our participants said that they struggled to engage with services often because they either lacked motivation to get to the hospital or they were in too much pain to complete that physiotherapy exercises, for example. So those were a couple of things. And I think there’s also one of the things that we find one of the problems that we think then as a finding from the study was that there seems to be not necessarily a dualistic on the part of the clinicians. I think that’s probably a little bit outdated given what we know about current pain understandings.
Daniel Board: 06:18 But I think there still is that perhaps a dualistic tendency in the organization of services, particularly in the UK. And I’m sure it applies to other countries as well, that if you have a physical problem, you go and see the physical services. If you have a mental health problem, you go and see the mental health part services. And I think that leaves populations like torture survivors who present with a really complex mix of all of these factors in quite a precarious position. So for example, they might come to a pain service, I’ll see a physio, and they might say, Oh, you look like you’re really struggling with PTSD. Let’s get you some help with that and then come back and see me. So then they’ll get referred to a psychological service, but they might struggle to engage with the psychological service because of the pain that they’re in. So it just seems to be, I think the service provision we have at the moment isn’t well suited to this population.
Karen Litzy: 07:07 And so is this population, they’re not being treated collectively. So if they’re going to see, let’s say you for pain, they’ll see you and then if they’re referred to psychologists or psychiatrists, they stopped seeing you and go see a psychiatrist or psychologist. It’s not happening at the same time.
Daniel Board: 07:28 So at the moment, no, not in the general health services. I think the key thing with any care and specifically with this population is it is very individualized, each of their particular problems or the things that are affecting the very individualized. So, for example, we might have someone who gets referred to the pain clinic I work at and they might really be struggling with their mental health. They might be really struggling with PTSD, having regular flashbacks. And what we try and do is assess the weight of the various physical, psychological and social components and help them kind of almost line it up. As in what do you think is the most important thing to get sorted first? Do you think you’ll be able to engage with the pain service?
Daniel Board: 08:13 You’ve actually got all this other really difficult stuff going on. So for those people we might say go and engage with a community mental health team, get some help with the PTSD and then come back. But that being said, I think that doesn’t mean that people who are undergoing sort of significant psychological distress can’t engage with pain services. So what we’ve started to do, we’ve just set up, a specific exercise class for this group of people, which is psychologically supported. So myself and one of my psychology colleagues, we’ve kind of paired the approach right down to keep it simple and actually you say kind of we understand you’re really struggling with your pain problem. We can try and help you or try and help it impact you less. So actually setting some goals with you. We use the patient specific functional scales are really nice outcome measure if keep going, what do you want to do? I’m really struggling to bend over. I can’t play with my kids. I can’t climb stairs. Okay, great. Let’s see if we can start doing that. And I think well slightly off on a tangent. Pain education is a really important part of that. But I think sometimes it gets lost in translation particularly.
Karen Litzy: 09:23 Yeah. I was just going to ask if it is a language barrier talking about pain education, we know that we can simplify it. Not Dumb it down but we can simplify it. But if there is this language barrier that Gosh, that must make it so much harder.
Daniel Board: 09:35 It is really, really difficult and there is some really nice work being done. The evidence base is limited, but there is some really nice work being done. April Gamble, who is a researcher who I’ve met here with the conference has done some really nice work looking at pain education in groups within their cultural setting and has come up with a variety of different tools that can be a cultural accessible tools that can be used. So she’s definitely a person, a good person to speak to you. I think what we try and do in the clinic is find one very simple metaphor that we can use with patients. So I’ll talk a lot about the volume on your nervous system being really high or I don’t know, when you’re assessing you find something that works for them and then when we’re doing stuff in Vivo, kind of let’s do some exercises, what’s showing up for you?
Daniel Board: 10:23 Kind of what thoughts are coming in your head, how that might be a barrier and that’s where the psychologist is really helpful. But then looking at reassurance, lots of reassurance and actually, okay, you’re not damaging yourself. It’s just a volume knob on high and I will mimic turning up a volume knob about a million times a day, I think with my patients. And yeah, it seems to work well for a group. But again, we can’t be prescriptive and actually it doesn’t work with everyone and we still need to look at other ways of engaging that group that it’s not necessarily working for.
Karen Litzy: 10:55 Yeah, great thoughts. Thank you. And anything else? Did we miss anything else from the study?
Daniel Board: 11:04 So they key things, I’ll summarize them cause I can remember them cause we just talked about them. I guess the key things were that there was a distinct lack of recognition of torture experience when diagnosing and treating pain. There was something which we haven’t overly covered, which was that the patient clinician relationship.
Karen Litzy: 11:23 We’re going to touch on that in a second. That was my next question, but go ahead.
Daniel Board: 11:27 We’ll hold that one. And then the last thing was the current organization of health care services and how that’s not necessarily conducive to such a complex population.
Karen Litzy: 11:36 My next question, if you didn’t bring it up, was going to be how do you as the therapist, how are you able to connect number one and number two, is there a burnout rate for the therapist, working with people in this population? Because if you’re an empath, let’s say someone who’s very, very empathetic, I would think this would be a really tough group to work with until you kind of get your bearings with them. So can you kind of touch upon that?
Daniel Board: 12:08 Absolutely. Starting with your question about the patient kind of clinician relationship and how you foster a kind of a good therapeutic relationship. I think you can probably over complicate it a little bit. I think from a therapist perspective, I think one of the key things that we have as physiotherapists is we’re very good at talking to people and we’re very good at helping people kind of be open. And I think actually what physios in the clinic, when we spend time with people, we’re often the first sort of people that they might have told about that specific problem. I think we’re really lucky. I’m really lucky that I’m able to work with psychologists, so if there’s anything that is really significant that they’re on hand and they can help me.
Daniel Board: 12:53 But I think as Physios, certainly when I was not working in pain, I think we look at mental health as a bit of a Pandora’s box. And I think there is a fear amongst some therapists of going, well, I don’t know. I don’t want to ask the question about your mental health or how your depression is, or whether you’ve been taught, for example, because I don’t know what I’m going to do with that information afterwards. So if I get an impression of you being a low mood and then you tell me that you’ve got some suicidal thoughts, I’ve got to act on that. And that’s scary. So I think personally myself, I used to be perhaps that way inclined. But actually I think as I said, we’re very good at talking.
Daniel Board: 13:31 A lot of what we do is talking as a profession. And I think actually just having a really good listening ear to someone, being able to say the things that come naturally to you with patients. So I’m not acting in shock at someone’s telling you what’s happened to them or avoiding questions about things that might be difficult and then dealing with whatever it is that comes up and that probably will have an element of you knowing what your support processes are within your service. So we have a really good pathway for suicidal ideation, for example. I think that patient clinician relationship is really, really important. And I think we as therapists, we’ve got really good chance to just be open and talk to patients. In the same sentence though, not with all survivors specifically. One of the things in the study was that actually some people really wanted to tell you about their experience and some people didn’t. Some people were really avoidant of it. And I think it’s just being careful that you’re not overstepping. Just being kind of a really sensitive approach is important.
Karen Litzy: 14:31 So the other question was, as the therapist, how do you protect yourself from burnout, from feeling just so empathetic towards these people that you’re taking it home with you at the end of the day?
Daniel Board: 14:46 I guess there’s a couple of things. I’m very lucky as I said that I work with a really good team of Physio, psychologist, doctors, nurses, and I would feel very comfortable being able to say or talk about anything that I was worried at with them. I think, sadly you do get a bit used to those conversations at times. I think they do affect you less. But inevitably you’re going to hear stuff, which is, which is horrendous. And I think the key thing in the same way that you would do with any other kind of mental health is not keeping it bottled up and actually if you need support, being able to talk about it, with your colleagues to get some support if you felt that that was needed.
Karen Litzy: 15:23 Yeah. No, that’s fair. That’s fair. Well, I mean, I have to say I think it’s a wonderful service that you’re providing for this group. It’s not easy. I have never worked with that population so I can’t put myself in your shoes. But I admire it greatly because these are truly marginalized group of people who really need the care. So congratulations to you and your clinic on doing this.
Daniel Board: 15:50 Thank you. I think this population encounters physios every day, I think we’re just lucky that we’ve got a service, which is nicely set up to help the people.
Karen Litzy: 16:00 Yeah. All right. So I have one last question before we finish. Well two actually, but we’ll start with one and it’s a question that I ask everyone. So knowing where you are now in your career and in your life, what advice would you give to yourself as a new Grad straight out of physio school?
Daniel Board: 16:19 Very, very good question. As a new Grad, I’m going to say is probably the key thing is say yes to everything. Opportunities. A good physio colleague of mine, Dave Reese when I was applying to do the masters of research we did last year, I was unsure. I kind of had that imposter syndrome and I think we often feel that, and he said a really good, a good thing, just lean in. So any of those kinds of experiences, which might seem scary, like presenting at a conference or being interviewed for a podcast or whatever it might be in your professional life, whether that be clinical research, I think, yeah, just take any opportunity to develop and learn from people that perhaps know more than you.
Karen Litzy: 16:59 Great Advice. And then lastly, where can people find you if they have questions they want to follow you on social media, where can they find you?
Daniel Board: 17:05 I’m relatively active on Twitter and my Twitter name is @BoardDan that’s probably the easiest way to get me as well.
Karen Litzy: 17:14 Perfect. And just so all the listeners know, we’ll have links to your clinic and links to everything at podcasts.healthywealthysmart.com. So you can go over there one click and it’ll take you to anything if you want more information. So, Dan, thank you so much for taking time out of your day at WCPT. And everyone, thanks for listening. Have a great couple of days and stay healthy, wealthy, and smart.
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