Listening is Therapy!

Listening is a significant part of the therapeutic encounter, we have to work on it.

Listening is a significant part of the therapeutic encounter, we have to work on it.

Louis Gifford (2014)1 first put forward the mnemonic ABCDEFW as a framework to guide the clinician through important questioning regarding psychosocial risk factors.

Once red flags have been ruled out and the predominant pain type stablished, a distinction between adaptive and maladaptive pain can be made. Adaptive pain is beneficial to the organism and alerting to percieved threat wheras in maladaptive pain the issue is in the nervous system itself, the alarm has been sensitised. Diener et al. (2016) 2 describe how psychosocial factors are often attributable to a sensitised nervous system, also known as 'yellow flags'. It can be suggested that in any case where pain has persisted beyond the expected healing times of the tissue involved that there is some element of sensitisation (Louw & Puentedura, 2013). 3 Almost all tissues in the body heal within 3-6 months (Louw, 2014) 4.

Pyschosocial factors are referred to in the literature as yellow flags. 

Pyschosocial factors are referred to in the literature as yellow flags. 

Yellow flags have been shown to predict worse outcomes in clinical practice. While there remains debate within the field, it has been shown that targeting these factors as part of the intervention does improve clinical outcomes (Nicholas et al. 2011)5.

The mnemonic ABCDEFW enables the clinician to explore those factors that need challenging and potentially reconceptualising. An expansion of the mnemonic was produced by Diener et al. (2016)2 in a great paper aptly titled 'listening is therapy':

Attitudes & Beliefs

Key Question: What do you think is the cause of your pain?

Information gained:

  • Fear avoidance
  • Catastrophization
  • Maladative beliefs
  • Passive attitudes toward rehabilitation 
  • Expectations of effect of activity or work on pain 


Key Question: What are you doing to relieve your pain?

Information gained: 

  • Use of extended rest
  • Reduced activity levels
  • Withdrawal from activities of daily living (ADL) and social activities 
  • Poor sleep
  • Boom-bust behaviour
  • Self medication - alcohol, over the counter (OTC) or other substances

Compensation Issues

Key Question: Is your pain placing you in financial difficulties? 

Information gained: 

  • Lack of incentive to return to work
  • Disputes of eligibility for benefits, delay in income assistance 
  • History of previous claims
  • History of previous pain and time off work

Diagnosis & Treatment

Key Question: You have been seen and examined for your pain? Are you worried that anything may have been missed?

Information gained: 

  • Health professional sanctioning disability
  • Conflicting diagnoses
  • Diagnostic language leading to catastrophization and fear
  • Expectation of 'fix'
  • Advice to withdrawal from activity and/or job
  • Dramatisation of back pain by health professional producing dependency on passive treatments


Key Question: Is there anything that is upsetting or worrying you about the pain at this moment?

Information gained: 

  • Fear
  • Depression
  • Irritability
  • Anxiety
  • Stress
  • Social anxiety
  • Feeling useless or not needed


Key Question: How does your family react to your pain?

Information gained: 

  • Over protective partner / spouse 

  • Solicitous behaviour from spouse 

  • Socially punitive responses from spouse 

  • Support from family for return to work 

  • Lack of support person to talk to


Key Question: How is your ability to work affected by your pain?

Information gained: 

  • History of manual work
  • Job dissatisfaction 
  • Belief work is harmful 
  • Unsupportive or unhappy current work environment 
  • Low educational background
  • Low social-economic status
  • Heavy physical demands of work 
  • Poor workplace management of pain issues
  • Lack of interest from employer

Louis Gifford describes how targeting these factors identified through ABCDEFW questioning can turn otherwise indicators of a poor outcome into indicatiors of a good one. These have been described as 'pink flags'.

Reconceptualising yellow flags into good predictors of outcome have been described as pink flags

Reconceptualising yellow flags into good predictors of outcome have been described as pink flags


If someone with persistent pain has become dependent on passive coping strategies (bed rest, clinician 'fixing' them through passive techniques like manipulation or needling, amongst many others...) this is a yellow flag. 

If these beliefs have been successfully challenged and reconceptualized then this person would move towards a much more proactive approach to managing not only their pain, but them-selves. This is a significant factor in predicting better outcomes in terms of disability5 and serves as an example of a 'yellow flag' turning into a 'pink flag'.

Listening is therapy, make sure you can guide the interaction with appropriate questioning (ABCDEFW) so as what you listen to can actually influence outcomes for the better. 


Luke R. Davies :)



1. Gifford, L. (2014). Aches and Pains: TJ International, Padstow, Cornwall, UK.

2.  Diener, I., Kargela, M. and Louw, A. (2016). Listenning is Therapy: Patient Interviewing From a Pain Science Perspective, Physiotherapy Theory and Practice,DOI: 10.1080/09593985.2016.1194648

3. Louw, A. and Puentedura, E. (2013). Therapeutic Neuroscience Education; Teaching Patients About Pain, International Spine and Pain Institute, USA.

4. Louw, A. (2014). Why You Hurt, Neuroscience Pain Education Cards, International Spine and Pain Institute.

5. Nicholas, M., Linton, S. J., Watson, P. J. and Main, C. J. (2011). Early identification and Management of Psychological Risk Factors ("Yellow Flags") in Patients with Low Back Pain: A Reappraisal, Working group. Physical Therapy; Washington, P.737-53.