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The Healthy Pain Conversation

By Noigroup HQ Education for all, Lost in translation 19 Oct 2018




Explaining pain or indeed explaining any symptom or medical condition is a conversation. The critical element of healthy conversation is invitation – a feature that we usually don’t think about when we chat.  Good conversation involves seeking permission to contribute and providing an invitation for others to contribute. There are many ways to do this. When, how and what to contribute is a complex snap second decision based on conversation gaps, timing, non-verbal nuances, subtle skills of seeking permission to speak, previous conversation status, knowing or sensing the other’s values, knowledge and emotional status, non-verbal validation of the other’s contribution and knowing when to pursue a topic. The list could go on. Healthy conversation is also about knowing when not to contribute or reasoning your ’dose’ of contribution. No one likes being spoken over.

Didactic delivery can be contradictory to healthy conversation. ‘Didactic’ is a sharp and abrasive word. It’s likely that a one-size-fits-all delivery approach, just poured out without regard for conversation skills or context, will have an abrasive effect. It misses simple but powerful conversation catalysts such as overt invitations “that’s interesting, tell me more” or  ”what do you mean by…’ in response to an open ended comment or figurative statement. Even just “hey wow! or even ‘let me know if I am bothering you” or ‘gosh, what did you learn from that experience?’. It misses the powerful non-verbals – a raised brow is an invitation as is supination of the hand. When explaining pain, simply ascertaining if a person wants to know about pain and mutually setting goals are healthy conversation enhancers.

Conversation skills are being lost. Blogs and forums routinely discuss the digital age and loss of communication and conversation skills. There is little in social media conversations to enhance conversation. I also feel that over the years, I am spoken over and spoken at rather than to. Maybe this lost skill is one reason why rote models of explaining pain and health issues are so common.

I would like to share a nerdy habit that I have always had. After dinner in a foursome, I will always do the maths – did we all talk 25% of the time? Did the 75% listen to the 25%? With a patient, is it 50/50? I will admit to rarely achieving this, but I try my best and I try to remember that we are both story telling.  And a healthy pain conversation is when the stories emerge effortlessly from both parties.

I would love a conversation about this!



  1. John Barbis

    It takes intentional practice, practice and more practice to get it right along with constructive feedback. These skills do not happen on their own or come out of thin air. Communication techniques are a skill just as specific spinal manipulations are a skill. Often those skills that seem the simplest or patently obvious are the most difficult to perfect.

  2. Great post David! So many people (including clinicians unfortunately) have two modes: talking and waiting to talk. By being a respectful communicator, we build trust and rapport – firmly embedding us in the “social” of the patient’s biopsychosocial framework. This helps our messages be better received since it reinforces the idea that we are an ally and not just a clinician who delivers a treatment. When you paint yourself into the role of “deliverer” the patient has no choice but to take the role of “receiver”, setting the stage for them to be a passive participant – which as we all know does not work!

    P.S. I’m a HUGE fan of both you and Lorimer, keep up the good work!

  3. davidbutler0noi

    Hi all – thanks for the comments. Stephanie – A good reminder for us all to be careful. Lorimer and I do suggest breaking the massive number of variables in an educational outcome into deliverer, learner, context and message domains for ease of management. It may hint at a deliverer/learner dichotomy but hopefully we have suggested wide deliverer competencies in our writings.

    I think the critical thing with listening and an awareness of invitation potential in conversation is to give the learner every chance to self express – for them to take your words, chew on them for a bit and them offer them back in their own words and context in an atmosphere than then allows you to easily comment.
    As John notes – not an easy skill – no devices during meal times may be a place to start! –
    I went our for dinner last night – 3 of us. It was a 40/ 30/ 30 % outcome! But the 40 percenter did have something special to discuss. And we 30 percenters were active listeners. Pinot helped!

    Have a successful weekend!


  4. Jon Dearness

    Well said. I’ve always found effective listening is an underappreciated skill in our armory. The patient’s story needs to be told. Patients will always believe what they say more than what they hear. This is where skilful non judgemental listening ,the use of open ended questions, and appropriate facts given gently with permission can change a patient’s narrative to one that makes sense clinically and more importantly makes sense to them. And most importantly they become the story tellers. These techniques will put the patient back in the centre of the treatment.

    Come on Dave, 50/50 in a conversation with you ?? ……….I’d like to see that !!😂

  5. Hey, I’m just a pain recipient trying to make more and more sense of my dreaded Persistent Pain, but I wanted to say that I LOVE your nerd alerts. They make me laugh almost as much as the Ted Talk about Hammer Head Shark Man stopping for a bite to eat before hospital, and clips of Lorimer’s snake bite tale in action. And, with that PP, every laugh is a little SIM! So, please, keep the nerd alerts coming because they’re the little sprinkle of chocolate powder in the shape of a heart on my extra-special coffee.
    I also love the lesson learned from you applying fractions to talk time in each after-dinner convo. Though I’m definitely not a clinician, but am a huge talker. I think I’ll have to divvy up my own conversations that way too, listening more, appreciating more, and extracting every little SIM I can from just sitting down with family and eating something good together.

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