Patricia J. Robinson, PhDMountainview Consulting Group

behavioral-health-integration.com patti1510@msn.com

(509)307-5333

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Workshop Overview

Learn strategies for teaching ACT to medical colleaguesBased on an ACT conceptualization of

experience of chronic pain in the primary care setting

Learn techniques for using ACT in monthly primary care classes, and ways to integrate the class into a primary care pathway approach to delivering services

Learn strategies for preventing onset of chronic pain

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Abbreviations & DefinitionsPCP= primary care providerPC= primary careBHC= behavioral health consultant“Addiction”= impaired control, compulsive use,

cont’d use despite harm, cravings“Dependence”= state of adaptation manifested by a

withdrawal syndrome if the drug is decreased/stopped

“Chronic pain”= noncancer pain lasting > 3 months“Misuse”=unintended use (recreation, give away,

sell)ACT=Acceptance and Commitment Therapy

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Chronic Pain in PC: Basic Info10-20% of PC pts report CP (Guereje et al.,

1988)14% of PC pts with CP need tx for it (Smith et

al., 2001)Most CP pts are treated in PC (Khouzam, 2000;

Olsen & Daumit, 2002) and the number is risingMismatch between patient expectations and PC

and BH abilities, resulting in relationship problems

HC Resources limited, specialty services often inaccessible

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Chronic Pain in PC: Basic InfoPCP training “sorely lacking” (Olsen & Daumit,

2004)Survey of residents: mean 2.2 and 2.3 for

preparedness and confidence, respectively, for treating CP (1-5 scale) (Fagan, 2007)

15% of PCPs feel comfortable with TX of CP (Potter et a, 2001)

Lack of specialty helpApplication bio-medical model which works well

with acute problems and many problems with organic basis

Time

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Chronic Pain in PC: Medication TX InfoAs pain medications become more powerful,

pain sensitivity increasesCharges of under-treatment of painUnclear effectiveness after 4 months

(Marteil, et al)Studies often show decreased pain but not

increased functionStudies lacking (use inactive placebos,

unclear methods, lack long-term)

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Chronic Pain in PC: Medication TX InfoAddiction and Overuse (self-medicating)

181% increase in opiod abuse in 90s (NIDA, 2005)

25-30% of PC pts abuse meds (Chelminski, 2005, Reid, 2002)

Diversion and Misuse (recreational) commonFear of DEA is a deterrent to RX’ing (Olsen &

Daumit, 2004) (Criminal charges after Oxycontin deaths)

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Evidence for an ACT Approach to CP: Evidence vs. ExperienceAttempt to suppress pain tends to increase it

(Cioffi & Holloway, 1993)

ACT interventions improve tolerance of pain in normal populations more so than CBT interventions (Gutierrez, Luciano, Rodriguez, & Fink, in press; Hayes, Bissett, Korn, Zettle, Rosenfarb, Cooper, & Grundt, 1999)

Acceptance accounts for more of variance in outcome on pain, depression, anxiety, disability, vocational functioning, and physical functioning than existing measures of coping with pain (McCracken & Eccleston, 2003)

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Physical damage bears little relation to amount of pain and relationship between functioning and pain is weak; willingness to experience pain and ability to act in a valued direction while experiencing pain predicts functioning (McCracken, Vowles, &Eccleston, 2004, later in week at conference!)

Supportive uncontrolled studies of ACT-based pain programs (Robinson & Brockey, 1996)

Controlled clinical trials supportive (Dahl, Wilson, & Nilsson, 2007)

Experiential Exercise

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Experiential Exercise

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Experiential Exercise

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ACT Perspective:Challenges to PC Management of Chronic PainPrimary care providers struggle with

problematic relational framesPrimary value is to help (most compassionate

sometimes most vulnerable)Lack of training and lack of positive impact

promotes avoidance (“Oh my gosh, Mr. X is here again, and I have no idea . . .”)

Limited timeLimited resources for responding to

demanding and/or aggressive pt behavior (often no BH provider on team)

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ACT Perspective:Challenges to PC Management of Chronic PainPatients with (vulnerability to) chronic pain

Have histories consistent with development of problematic relational framesLack of control and danger (trauma backgrounds)Negative mood states and avoidant response

strategies (withdraw when “down”)Use of alcohol / drugs to avoid suffering Victim, aggressor perspective (right / wrong)

Limited skills for mindfulness and acceptanceLimited support for value-consistent actions

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ACT Perspective:Challenges to PC Management of Chronic PainMedications (oral and other) have

problematic relational frames“Magic” and often free“Happy” pills“Holding the wolf at the door”“More would be better”

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ACT Perspective:Challenges to PC Management of Chronic PainPain detection and elimination are foci of

primary care servicesThe Fifth Vital SignMedical Model (search for organic basis)Often delays between transition from treating

acute pain to treating chronic pain (awaiting specialist care) Pt practices avoidance strategies Pt’s behavior becomes less consistent with values

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ACT Perspective:Challenges to PC Management of Chronic PainChronic pain is pain and unwillingness to

have itDistress prominent in patient presentationAcute to chronic phase: More anxiousChronic: More depressed, angry, demanding,

dull

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An ACT Perspective on Challenges to PC Management of Chronic PainTendency for treatment of chronic pain to be

some one else’s jobReferral to specialist (curative)Specialist return of pt to primary careReferral to pain clinicPain clinic return of pt to primary care

Tendency to see chronic pain treatment problems to be due to care delivered by someone elseInitial or previous prescriber of pain medicationsFailed back surgeryLabor & Industry open claims

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Teaching ACT to PC Providers: The ProblemFusion (attachment to scary and/or depressing

thoughts, pt and provider)Evaluation of pain/fear/discouragement/

depression in good-bad terms (pt and provider)Avoidance of unwanted private experience (pt:

victim or aggressor behavior, provider: hand on the door)

Reason giving to explain behavioral excesses or deficits (pt: The pain/provider – is the reason --- for X; PC provider: The pt is – difficult –a tx failure, a drug seeker, etc.)

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Fusion: Patient and ProviderFusion is treating

our thoughts as if they are what they say they are.

Fusion with thoughts about the unacceptability (dangerousness, shamefulness, isolating qualities) of pain

Patient: “This is what happened to me . . .”

“This pain is killing me. It’s a 10 and I can’t take it any more! ”

“I’m damaged and no one cares.”

PCP/BHC: “Maybe, but I want to

help you . . . .”“He looks like an abuser

to me!”21

Teaching ACT to PC Providers:The AlternativeAccept (what is present inside and outside the

skin)Pt: Pain and lack of controlPC Provider: Unsatisfied patient and lack of

controlChoose (a valued direction)

Pt : QOL consistent with valuesPC Provider: Practice consistent with values

Take action (valued, over and over again)

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The Message: Over and Over AgainChronic Pain Is

Pain and Unwillingness to Have ItResulting in Overuse of Avoidance

Strategies (in regards to internal and external stimuli) . . .

This results in Psychologically Inflexible Responding (which limits one’s ability to pursue valued directions in life)

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3 ACT R Styles (Imagine an aerial view of a 3-legged stool)

Aware: Present in Moment

And Willing to . . . Engaged:

Clear in Values and Actively Pursuing

Open: De-Fused and

Accepting

PsychologicalFlexibility

Open: Defused and AcceptingHands to face and breathing them outNose on computer and breathing self out 2

feetOn-going 5 minute morning practice (pt at

home, MD and RN in clinic)Jotting down thoughts on paper (carrying in

pocket of pt coat, provider’s white coat)Physical rope in room (picking up when

struggle begins, changing use of space to allow pt and provider to hold it together

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Aware: Present in Moment and AcceptingBreathing togetherBowl of chronic pain soupHolding bowlDescribing negative thoughts and feelings

aloud, as disliked and integral ingredients in soup

Songs on a CD played in the clinic Eagle’s Eye view

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Engaged: Clear in Values and Actively PursuingValues vs. Goals (Plane Crash on a Dessert Island)Value Statement: Love, Work or Play(Alternatively, Relationships, Health,

Work/Study, Play/Spirituality)Bull’s Eye Prescription PadConsistency pat 2 weeks, consistency score after

initiation of ACT strategiesExploration of barriers Teaching ACT skills that address the barriers

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MD, RNs, BHCs: Intervention and Preventions

RX Pad for Prevention, 1-page handout used repeatedly at class

Keep values at the center of patient and provider interactions

Strengthen PC and Pt, BHC and Pt relationships

Strengthen relationships between pts

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Intervention Pathway

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Factors Associated with Increased Risk of Misusing Opiods (ORT)

Family History or Personal History of Problems with

alcohol useUse of illegal

drugsMisuse of RX

drugs

Age (18-45)History of childhood

sexual abuse (for women)

DX of DepressionADHDOCDSchizophrenia

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Intervention Pathway

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Factors Associated with Increased Risk of Misusing Opiods (ORT)

Family History or Personal History of Problems with

alcohol useUse of illegal

drugsMisuse of RX

drugs

Age (18-45)History of childhood

sexual abuse (for women)

DX of DepressionADHDOCDSchizophrenia

Class OrganizationIntroduction(s):

Of class members (new and on-going), includes topic suggestions (specific to barriers to valued actions since previous monthly meeting)

Of ACT model Workability of pain elimination, avoidance, control Value consistent action (Bull’s Eye Handout)

Assessments:Healthy Days QuestionnairePain Acceptance Questionnaire (quarterly)

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Class OrganizationMedication Sign Up List

Pt sign inDelivered to pharmacy for RX fills

1:1 Check-insBHC goes round tableLooks at assessment results, compares with

previous findings, notes pt need for 1:1 with PC if such exists

Work individually or in pairs discussing values and value directed behavior change results

Acknowledgement of birthdays, efforts34

Class OrganizationAcknowledgement of birthdays (Pain, pain,

pain)Acknowledgement of value consistent action,

commitment statements, exercises Skill work, experiential exercisesEnd (BHC charts / includes description of

exercise / skill and individual pt outcomes)

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Class Interventions: Goals and Workability

What is your goal with pain? (stop, eliminate vs. live with / manage)

What have you done to try to achieve that goal?

How has that strategy worked in the short-term? In the long-term?

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Class Interventions: DeFusionCourage BreathPain, pain, pain (tune of Happy Birthday)Passengers on a BusSilent together and holding our thoughts and

feelings lightly, like we might hold a crying baby

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Class Interventions: Observer Self and MindfulnessObserver Self vs. Self as Content (story)

Life Circle Time Line

MindfulnessWise SelfEagle River video, Eagle perspective

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Prevention Pathway

Patient Interventions: Actions Consistent with ValuesClarifying values Committed Action

Making and implementing behavior change plans that are consistent with values

Bull’s Eye

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Patient Satisfaction

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PCP Satisfaction

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PCP Top RatingsYear 1: Able to access effective programs,

Have skills to work effectively, Look forward to seeing CP patients

Year 4: Able to access effective programs, Pain meds are very helpful, Have skills to work effectively

Year 5: Pain meds are very helpful, Able to access effective programs, Have skills to work effectively, I usually have a new idea about how to help my most difficult CP patients

Dr. Sauerwein Prevention of chronic pain

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