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A P P R O A C H E S I N M S A N D C H R O N I C P A I N M A N A G E M E N T
PAIN PSYCHOLOGY
WHAT IS PAIN PSYCHOLOGY
• Identifying, treating, and monitoring ‘the fallout’ related to suffering from physical pain
• Relies on an integrative, collaborative team approach• What Pain Psychology is not:
• Strictly long-term psychotherapy or “talk therapy”• Treating only those psychological symptoms suspected to be related to pain• A “one size fits all” model• Primarily focused on alleviating or reducing pain • A cure
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THE PATIENTS PERSPECTIVE
• “I am married to my pain. She is my wife. I may not always get along with her, but she is in my life and has made me who I am. We used to fight all the time, but now we have an understanding that she can’t control my life or make me miserable. In return, I’ve learned to really listen to her and to understand what she needs.”
53y.o., male, Post-Vietnam era Veteran
SHIFTING THE PARADIGM
• By its very nature, pain is unacceptable• Providers seen as the “experts” with the key
to the cure • Locus of control and responsibility
• Shift the focus• Pain signals are a message from the body• Teaching model
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A SELF-MANAGEMENT APPROACH
• Defined as: “more than compliance with a set of instructions, but is a dynamic process of maintaining health in the setting of chronic illness’’1
• Additionally, it is ‘‘the ability of the individual, in conjunction with family, community, and health care professionals, to manage symptoms, treatments, lifestyle changes, and psychosocial, cultural, and spiritual consequences of health conditions’’2
1Grey, M., Knafl K., & McCorkle R. (2006). A framework for the study of self and family management of chronic conditions. Nursing Outlook 54, 278–286.2Richard A.A. & Shea, K. (2011). Delineation of self-care and associated concepts. Journal of Nursing Scholarship, 43, 255–264.
SPECIFIC CONSIDERATIONS
• Locus of Control • External locus of control is associated with depression, anxiety, and disease
progression1
• Internal health locus of control is associated with greater disease knowledge, increased self-care, and more benign disease course2
• Has implications for readiness to apply a self-management approach• Self-Efficacy
• Motivation is necessary but not sufficient• Providers present for only a fraction of the patient’s life (Barlow, 2003)
• Nearly all outcomes are mediated through the patient’s behavior(Bodenheimer et al., 2002).
1 Vuger-Kovačić, D., et al (2007). Relation between anxiety, depression and locus of control of patients with multiple sclerosis. Multiple Sclerosis, 13(8), 1065-1067
2 Wassem, R. (1991). A test of the relationship between health locus of control and the course of multiple sclerosis.
Rehabilitation Nursing, 16(4), 189-193.
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SELF-MANAGEMENT: THE ESSENTIALS
• Three broad processes underlying self-management have been identified1, 2:• 1)Focusing on illness needs:
• learning about the condition• developing strategies to manage illness tasks• taking ownership of health needs
• 2) Activating resources:• identify and access various resources to support efforts, including
health care, social, spiritual, and community supports• 3) Living with a chronic illness
• recognizing the emotional responses to living with a persistent illness and developing strategies to integrate wellness into daily life
1Schulman-Green, D., Jaser S, Martin, F., Alonzo, A., et al. (2012). Processes of self-management in chronic illness. Journal of Nursing Scholarship, 44, 136–144.
2Novak, M., Costantini, L., Schneider, S., & Beanlands, H. (2013). Approaches to self-management in chronic illness. Seminars in Dialysis, 26(2), 188–194.
HOW DO WE USE THIS INFORMATION TO DISSEMINATE USEFUL, PATIENT-CENTERED TREATMENT?
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CURRENT MODEL OF PAIN MANAGEMENT
ILLNESS NEEDS: EDUCATION
• Chronic versus acute pain:• Not typically an indication of immediate danger• Biological mechanisms not always well understood• Can manifest as chronic emotional stress• Important to balance activity with contingent rest• Role of the provider: teacher and advisor• Role of the person with pain: partner in health care
responsible for daily management
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ILLNESS NEEDS: EDUCATION CONT’D
Slides courtesy of Brian Morrison, D.C.
WHO HAS PAIN?
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ILLNESS NEEDS: COPING STRATEGIES
• Action plans • Meaningful, Realistic, Specific, Flexible, Positive, Written,
How confident?• Don’t forget the follow-up
• Problem-solving: Identify, List ideas, Select, Assess, Rinse and Repeat, Accept
• Pacing• Monitor, Time-based, Plan ahead, Rest often
STAGES OF CHANGE
Image credit: Engender Health, 2003
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ENHANCING READINESS FOR CHANGE
1 - small action plans 2 - how they had made hard choices 3 - how they resolved a difficult situation in the past
1 - note and affirm progress 2 - plan for relapse 3 - identify and remove obstacles to maintaining course of action
1 - provide information 2 - offer assistance at every visit 3 - accept the situation
1 - explore discrepancies in information 2 - explore pro’s and con’s of the change 3 - discuss hierarchy of values
ConfidenceI
mportance
STAGES OF GRIEF
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ACTIVATING RESOURCES
• Provider plays a pivotal role• The peer-connection
LIVING WITH A CHRONIC ILLNESS
Courtesy of Vanderbilt Health: http://www.vanderbilthealth.com/integrativehealth/10951
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PHYSICAL BODY
1Oken, B.S., et al. (2004) Randomized controlled trial of yoga and exercise in multiple sclerosis. Neurology, 62, 2058-2064.
• Mat or Chair Yoga-energy & fatigue 1
• Tai Chi/Qi Gong• Massage and self-
massage• Reconnect with body
ENVIRONMENT
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ENVIRONMENT
CONNECTION
SOCIAL• Fostering positive
relationships• Support groups
• Community groups
• Spiritual communities
• Pets
INTELLECTUAL• Vocational
Counseling• Volunteering
• Hobbies
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EMOTIONAL HEALTH
Gratitude ritual Positive Reframing
PlayMindfulness
WHAT IS MINDFULNESS?
• Consciously bringing awareness to the ‘here-and-now’ experience with openness, interest, and receptiveness
• Primary elements:• Living in the present moment• Engaging fully in what you’re doing rather than ‘getting lost’
in your thoughts• Allowing your feelings to be as they are, rather than trying to
control them• Mindful eating exercise
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ACCEPTANCE AND COMMITMENT THERAPY (ACT)
• Rooted in the tradition of empirical science and has been termed ‘existential humanistic cognitive behavioral therapy1’• Considered part of the ‘third wave’ of behavioral therapies along with Dialectical Behavior Therapy (DBT) and Mindfulness-Based Stress Reduction (MBSR)• ACT gets it name from one of its core messages: accept what
is out of your personal control, and commit to action that improves and enriches your life
TENETS OF ACT
• Symptom reduction is not the primary goal • Attempts to get rid of symptoms fuels the clinical disorder
• ACT does not rely on an assumption of ‘healthy normality’ or that psychological suffering is abnormal• An estimated 1 in 10 Americans experiences depression (CDC, 2010)• Each year, more than 36,000 Americans take their own lives (CDC, 2009)
and about 465,000 people receive medical care for self-inflicted injuries (CDC, 2010)
• ACT assumes that suffering is a part of the human condition, and often a byproduct of the ‘normal’ human mind
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TENETS OF ACT CONT’D
ACT breaks mindfulness skills down into 3 categories: • 1) Defusion: distancing from, and letting go of, unhelpful
thoughts, beliefs and memories • 2) Acceptance: making room for painful feelings, urges and
sensations, and allowing them to come and go without a struggle
• 3) Contact with the present moment: engaging fully with your here-and-now experience, with an attitude of openness and curiosity
http://contextualscience.org/
WHAT THE RESEARCH SAYS
1) Small sample of MS patients: decreased depression, extent of thought suppression, impact of pain on behavior, and improved quality of life1
2) MS patient sample over 12 months: acceptance associated with improved adjustment 2
3) CBT versus ACT: ACT participants improved on pain interference, depression,
and pain-related anxiety there were no significant differences between the treatment
conditionsACT participants reported significantly higher levels of
satisfaction compared to the CBT participants3 1 Sheppard, S.C., Forsyth, J.P., Hickling, E.J. & Bianchi, J. (2010) A Novel application of acceptance and commitment therapy for
psychosocial problems associated with multiple sclerosis. International Journal of MS Care, 12(4), 200-206.2 Pakenham, K.I. & Fleming, M. (2001). Relations between acceptance of multiple sclerosis and positive and negative adjustments.
Psychoogical Health, 26(10),1292-309. 3Wetherell, J.L. (2011). A randomized, controlled trial of acceptance and commitment therapy and cognitive-behavioral therapy for chronic
pain. Pain, 152(9), 2098-107.
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THANK YOU!
CARYN SEEBACH, PSY.D.PAIN CLINIC PSYCHOLOGIST WASHINGTON, DC VA MEDICAL CENTER
