A Mindful Approach to Pain Management

Transcription

1 A Mindful Approach to Pain Management Julie Hamilton, ACSW, CAADC Objectives Ø Learn new mindfulness based approach to treatment of Pain Mgmt. Ø Pathological processes that contribute to and worsen pain and decrease life engagement. Ø Mindful based interventions that promote acceptance and engagement. Ø Identify benefits of mindfulness interventions in pain treatment. A1-B1: Hamilton 2 Where do we begin? LAUGHING BABY A1-B1: Hamilton 3 A1-B1: Hamilton 1

2 Cost of Pain Institute of Medicine, 2011 Cost to society, per year, as whole from chronic pain, including treatment and lost production is between $560 - $635 billion. A1-B1: Hamilton 4 Cost of Pain And what does it cost young people physically, emotionally, spiritually? A1-B1: Hamilton 5 MI-Youth Overdoses Ø Youth overdoses almost quadrupled in Michigan from to Ø Michigan s overdose death rate is higher than the national average for youth ages Ø Michigan placed 22nd highest among the states with a rate of 8.1 overdose deaths per 100,000 young people, compared with 7.3 deaths per 100,000 nationally. Trust for America s Health Report, 2015 A1-B1: Hamilton 6 A1-B1: Hamilton 2

3 A Profile of Drug Overdose Deaths Using the Michigan Automated Prescription System (MAPS) Over the past decade, the number of drug poisoning deaths have increased dramatically in Michigan. The rate of death from unintentional drug poisoning has almost quadrupled since 1999, driven by an increase in overdoses involving prescription drugs. Opioid analgesics (e.g., oxycodone, hydrocodone) are narcotic drugs that are prescribed to relieve pain and were involved in a large number of Michigan s prescription drug overdose deaths. The Michigan Automated Prescription System (MAPS) is a prescription drug monitoring program which reported over 20.9 million prescriptions written for controlled substances in Hydrocodone remains the highest prescribed drug since the creation of MAPS in 2003, accounting for 32.2% of all prescriptions in 2012 Michigan Department of Community Health, 2014 A1-B1: Hamilton 7 A1-B1: Hamilton 8 Ruth Pozdol, 38, mother of two. Walled Lake mother with heroin addiction goes on trial Monday accused of carjacking a senior, then running him over with his truck in parking lot of Waterford Burger King.once a successful property manager, but now caught up in an heroin addiction Baby boomers. They have aches and pains. They take a pill for the pain. It can be as simple as a trip to the dentist, and a prescription for Vicodin. Three days later, the addiction starts to set in. Tracy Chirikas, coordinator for the Oakland County chapter of Families Against Narcotics (Freep, 09/20/15) A1-B1: Hamilton 9 A1-B1: Hamilton 3

4 Treatment Kabot-Zinn, 2011 Treatments for pain management are all too often unsuccessful. A1-B1: Hamilton 10 Current Data NIDA 2011 Ø For moderate to severe pain prescribed opioid analgesics are first line of treatment. Ø opioid sales per capita up 600% Ø Prescribed opioid OD s higher than heroin/cocaine combined A1-B1: Hamilton 11 Trends Over Last Years (Portenoy, 2011) Ø Rapid increases in opioids prescribed by pain specialists, PCP s Ø Rapid increases in adverse outcomes: l Abuse, addiction, diversion l Unintentional OD behaviors leading to mortality Ø Evolving responses by: l Clinical community l Regulatory and law enforcement communities A1-B1: Hamilton 12 A1-B1: Hamilton 4

5 Changes Taking Place Ø Gov t. creating stricter scheduling categories. Ø Risk Evaluation and Mitigation Strategies (REMS) re: analgesics Ø Integrated Medical Certification Ø Pain Clinics adding newer approaches, such as ACT, MBSR A1-B1: Hamilton 13 Changes Taking Place At the same time- Ø Zohydro l High dose hydrocodone l Can be crushed and inhaled l Can OD on 2 pills Ø Medical marijuana A1-B1: Hamilton 14 A1-B1: Hamilton 15 A1-B1: Hamilton 5

6 Research (Russell Portenoy, 2011) Ø RCT s and systematic reviews re: pain management/opioid use are conflicted. Ø Opioid use appears to work on short term, conflicted results re: long term. Ø Portenoy-physicians need to work to prevent long term usage. A1-B1: Hamilton 16 Chronic Back Pain (Dahl, et al., 2005) Research shows much confusion: Some patients report continued back pain despite tests showing once existing pathologies have been eliminated. Some patients have visible pathologies, yet report no pain. A1-B1: Hamilton 17 Chronic Back Pain (Dahl, et al., 2005) Research shows much confusion: Pain is much more complex than just physical pathology. A1-B1: Hamilton 18 A1-B1: Hamilton 6

7 When a young client comes in with complaints of chronic pain...what goes through your mind?.what feelings show up? A1-B1: Hamilton 19 What do clients dealing with pain want to see happen when they seek treatment? A1-B1: Hamilton 20 What has the client gone through with pain by time they enter treatment with us? Ø Efforts to control, eliminate (pain killers ) Ø Behavioral changes Ø Life style changes Ø Thoughts, beliefs about themselves Ø Self-stigmatization A1-B1: Hamilton 21 A1-B1: Hamilton 7

8 Approaches Assist Clients with PAIN Ø CBT Ø Mindfulness Based Stress Reduction Ø ACT: Acceptance and Commitment Therapy (Psychological Flexibility) A1-B1: Hamilton 22 Experiential Avoidance A1-B1: Hamilton 23 Experiential Avoidance (Dahl et al., 2005) Our minds naturally try to protect us with avoidance. Pain patient who associates back pain with work/stress.may avoid thoughts of returning to work or dealing w/ stress.both in thought and action. A1-B1: Hamilton 24 A1-B1: Hamilton 8

9 Experiential Avoidance (Dahl et al., 2005) A serious pain problem/diagnosis is not something that is easy to hear or think about a permanent pain diagnosis is worse news yet. A1-B1: Hamilton 25 Experiential Avoidance (Dahl et al., 2005) However, an unwillingness to remain mindful of the pain/stress symptoms can have serious consequences. A1-B1: Hamilton 26 Experiential Avoidance (Dahl et al., 2005) If an individual is unwilling to think about their pain and feelings of stress, consider all of the events that might be associated with these symptoms that would also need to be avoided: A1-B1: Hamilton 27 A1-B1: Hamilton 9

10 Such as: Ø Doctors Experiential Avoidance (Dahl et al., 2005) Ø Medications Ø Symptoms Ø School-events Ø Social activities Ø Physical movements that previously precipitated it A1-B1: Hamilton 28 Pain and Suffering Cognition Emotions Physical Pain Avoidance A1-B1: Hamilton 29 Experiential Avoidance (Dahl et al., 2005) Any efforts to NOT think about pain and its associations triggers us to think about. A1-B1: Hamilton 30 A1-B1: Hamilton 10

11 Experiential Avoidance (Dahl et al., 2005) From the ACT/RFT perspective, what is needed in behavioral medicine are: Ø The procedures that can help the client manage their medical condition, and Ø The skills to cope with the psychological reactions to having that condition, through values, acceptance, defusion, and contact w/ the present as a conscious person. A1-B1: Hamilton 31 Experiential Avoidance Is it GOOD or BAD to avoid and/or control pain? A1-B1: Hamilton 32 ACT Philosophy (Hayes, Strosahl, Bunting, Twohig, Wilson, 2004) People inadvertently create more suffering for themselves by habitually reacting with short term attempts to avoid or control suffering. *Struggle vs. Accepting A1-B1: Hamilton 33 A1-B1: Hamilton 11

12 MIND A1-B1: Hamilton 34 The Mind Ø Analyzes Ø Evaluates Ø Predicts Ø Plans Ø Judges Ø Compares Ø Remembers LOCKED ROOM A1-B1: Hamilton 35 Avoid and Control Pain CLEAN vs. DIRTY Reactions A1-B1: Hamilton 36 A1-B1: Hamilton 12

13 Avoid and Control Pain The Mind as a Story Teller A1-B1: Hamilton 37 PAIN-FUL STORIES Ø Injured runner story. Ø Other PAIN-full stories Conceptualized Self vs. Self as Context A1-B1: Hamilton 38 New Wave of CBT Treatment: PAIN TREATMENT Mindful Based Approaches- Ø Mindful Based Stress Reduction- MBSR Ø Mindful Based Cognitive Treatment- MBCT Ø Acceptance and Commitment Therapy-ACT A1-B1: Hamilton 39 A1-B1: Hamilton 13

14 New Wave of CBT Treatment: Most of these are used for mental health, addiction and pain management. A1-B1: Hamilton 40 New Behavioral Approaches (Hayes, et al 2012) l Share MINDFULNESS as a Common Focus l Mindfulness practice assists clients in focusing in present moment as it is. l Without judgment l This can help clients be aware of thoughts, feelings, sensations that trigger unhelpful behavior. l This awareness allows for RESPONSE. A1-B1: Hamilton 41 MINDFULNESS Ø A way to live life fully with pain Ø Noticing vs. Thinking Ø 5-10 breaths Ø Noticing 5 senses- listening, touching, tasting, smelling, seeing Ø Without judgment A1-B1: Hamilton 42 A1-B1: Hamilton 14

15 Mindfulness Five Phases of Present Moment Awareness: Noticing what s there Naming what s there Detaching from what s there (letting go) Holding what s there softly (selfcompassion) Reframing the personal meaning of what s there (aka expanding) Strosahl and Robinson, 2015 A1-B1: Hamilton 43 Traditional CBT Ø Effective on the short term Ø Symptom reduction Ø Controlling repertoire Ø Thought Stoppage A1-B1: Hamilton 44 CBT in Pain Management (Vowles, 2008) For approximately two decades, psychological approaches to chronic pain have predominately relied on Cognitive- Behavior Therapy (CBT) as the primary treatment model (Flor & Turk, 1988; Turk & Monarch, 2002). A1-B1: Hamilton 45 A1-B1: Hamilton 15

16 CBT in Pain Management The importance of cognitive change, the primary process by which CBT for pain is theorized to work, has not been entirely supported. For example, it is not necessary to include methods directed at achieving cognitive change in order to achieve positive treatment outcomes (Vowles, McCracken, Eccleston, 2007). A1-B1: Hamilton 46 CBT in Pain Management.and the inclusion of these methods does not appear to reliably increase the effectiveness of treatment. (Smeets, Vlaeyen, Kester, & Knottnerus, 2006). A1-B1: Hamilton 47 CBT in Pain Management Furthermore, there is a lack of a coherent and consistent theoretical model in CBT, as it is not clear how the numerous beliefs, thoughts, and expectations which are reliably correlated with indices of functioning (e.g., catastrophizing, selfefficacy, readiness to change, threat appraisals) are distinct from or serve to influence one another. (Vowles, Wetherel, Sorrels, 2008) A1-B1: Hamilton 48 A1-B1: Hamilton 16

17 CBT in Pain Management Recent work in psychology generally, and in psychological approaches to chronic pain specifically, has focused on addressing some of these concerns. Perhaps the most widely researched of these approaches is Acceptance and Commitment Therapy (ACT; Hayes, Strosahl, & Wilson, 1999), which, although somewhat new, is amassing supportive evidence for its relevance and effectiveness. (see Hayes, Luoma, Bond, Masuda, & Lillis, 2006 for a review). A1-B1: Hamilton 49 ACT Research: Pain Management (Dahl, et al., 2005) Ø In a study on effectiveness of ACT interventions (4 hours) with pain patients at risk for developing long term disability from stress and pain symptoms, ACT reduced sick day usage by 91% over the next 6 months, as compared to treatment as usual (TAU). A1-B1: Hamilton 50 ACT Research: Pain Management (Dahl, et al., 2004) Ø In a study on effectiveness of ACT interventions (4 hours) with chronic pain patients who had missed work repeatedly over a year, but continued to work. Ø Used ACT protocol vs. MTAU. Ø N=24 Ø 6 month follow up A1-B1: Hamilton 51 A1-B1: Hamilton 17

18 ACT Research: Pain Management (Dahl, et al., 2004) Doctors Visits during 6 mo. f/u: Ø MTAU participants visited their MD s 15.1 times on avg. Ø ACT participants visited MD s at 87% lower rate: avg. 1.9 visits. A1-B1: Hamilton 52 ACT Research: Pain Management (Dahl, et al., 2004) Work Related Absences during 6 month f/u: Ø MTAU workers missed avg. of 56.1 days. Ø ACT workers missed work at 99% lower rate: avg..5 missed days. A1-B1: Hamilton 53 ACT Research: Pain Management Wicksell, R. K., Ahlqvist, J., Bring, A., Melin, L. & Olsson, G. L. (2008). Can exposure and acceptance strategies improve functioning and life satisfaction in people with chronic pain and whiplashassociated disorders (WAD)? A randomized controlled trial. Cognitive Behaviour Therapy, 37(3), A1-B1: Hamilton 54 A1-B1: Hamilton 18

19 ACT Research: Pain Management Wicksell, R. K., Ahlqvist, J., Bring, A., Melin, L. & Olsson, G. L. (2008). Ø N = 521 Patients with WAD Ø ACT and Control (wait list) Groups Ø 10 Session protocol (inc.: acceptance, exposure, values) A1-B1: Hamilton 55 ACT Research: Pain Management Wicksell, R. K., Ahlqvist, J., Bring, A., Melin, L. & Olsson, G. L. (2008). Ø Significant differences in favor of the ACT group were seen in pain disability, life satisfaction, fear of movements, depression, and psychological inflexibility. Ø No change for any of the groups was seen in pain intensity. Ø Improvements in the ACT treatment group were maintained at 7-month follow-up. A1-B1: Hamilton 56 ACT Research: Pain Management (Wicksell, R. K., Melin, L., Lekander, M., & Olsson, G. L. (2009). u N = 32 Adolescents w/ Chronic Pain u 10 weekly ACT sessions u Assessments were made before and immediately after treatment, as well as at 3.5 and 6.5 months follow-up. u Results showed substantial and sustained improvements for the ACT group A1-B1: Hamilton 57 A1-B1: Hamilton 19

20 ACT is: What is ACT Ø A New Behavioral Therapy (CBT) Ø An empirically based model Ø Based on Relational Frame Theory (RFT) Ø Short-term model Ø Solution Focused with Motivational components Ø Developed by Stephen Hayes, Kirk Strosahl, and Kelly Wilson A1-B1: Hamilton 58 ACT can: What is ACT Ø Be used as an exclusive model. Ø Blended with other models. Ø ACT interventions incorporated into variety of treatment modalities, including pain management protocols. A1-B1: Hamilton 59 Better Living with Illness Group Protocol Ø David Gillanders, et al, University of Edinburgh Ø Hot off the press so to say! Ø Access FREE* via ACBS membership ($10-$60.00) l A1-B1: Hamilton 60 A1-B1: Hamilton 20

21 Functional Analysis- ACT and Pain (Hayes, et al, 2011) Ø A. Consider general behavioral themes and patterns, client history, current life context, and in session behavior that might bear on the functional interpretation of specific targets in ACT terms. These may include: A1-B1: Hamilton 61 ACT and Pain 1. General level of experiential avoidance (core unacceptable emotions, thoughts, memories, etc.; what are the consequences of having such experiences that the client is unwilling to risk) 2. Level of overt behavioral avoidance displayed (what parts of life has the client dropped out of) A1-B1: Hamilton 62 ACT and Pain 3. Level of internally based emotional control strategies (i.e., negative distraction, negative self instruction, excessive self monitoring, dissociation, etc.) 4. Level of external emotional control strategies (drinking, drug taking, smoking, selfmutilation, etc.) 5. Loss of life direction (general lack of values; areas of life the patient checked out of such as marriage, family, self care, spiritual) A1-B1: Hamilton 63 A1-B1: Hamilton 21

22 ACT and Pain 6. Fusion with evaluating thoughts and conceptual categories (domination of right and wrong even when that is harmful; high levels of reason-giving; unusual importance of understanding, etc.) A1-B1: Hamilton 64 New Behavioral SA Approaches (Hayes, et al 2012) In ACT (K. Wilson) counselors help clients notice when they get caught up in their thoughts and selfstories, then redirect their attention to the present moment, i.e., through mindful breathing or another variation of mindful exercise. A1-B1: Hamilton 65 New Behavioral SA Approaches (Hayes, et al 2012) All these interventions fit within the umbrella of contextual treatments, because they focus on altering the context in which clients relate to their environment and internal experiences, i.e., past/future or here/now. A1-B1: Hamilton 66 A1-B1: Hamilton 22

23 Contextual CBT Approaches (Hayes, et al 2012) They shift from automatically reacting to their thoughts and feelings with out awareness of the consequences of doing so.to being present and aware of their experiences in the moment in a way that provides more flexibility and choice in how to respond. A1-B1: Hamilton 67 Contextual CBT Approaches (Hayes, et al 2012) Although the form and intensity of their internal experiences may stay the same in the interventions, the context in which they are experienced is altered in a way that allows clients to be more aware, non-reactive, and compassionate towards whatever is present. A1-B1: Hamilton 68 Contextual CBT Approaches (Hayes, et al 2012) This includes pain in all its forms A1-B1: Hamilton 69 A1-B1: Hamilton 23

24 ACT in a Nutshell Ø AWARENESS (mindfulness) Ø ACCEPTANCE/WILLINGNESS (making room for pain) Ø VALUED Directed Behavior (Action!) A1-B1: Hamilton 70 Today s Exercises Completely voluntary....are you willing? A1-B1: Hamilton 71 Exercise-Present Moment (Wilson, 2012) Six Breaths on Purpose Ø Close eyes or focus gaze on spot Ø Take six breaths Ø Notice physical sensations: warm exultation, cool inhalation, muscles stretching in abdomen, chest Ø Notice thoughts Ø Return to breath A1-B1: Hamilton 72 A1-B1: Hamilton 24

25 Thought Stoppage? A1-B1: Hamilton 73 The aim of ACT: ACT (Russ Harris) Ø To lead a rich, full, and meaningful life based on one s values Ø While accepting the PAIN that goes with it. A1-B1: Hamilton 74 Your Mind is not Your Friend or Your Enemy (Harris, 2009) HUMAN SUFFERING: What if we take the next half hour and dwell on our PAIN A1-B1: Hamilton 75 A1-B1: Hamilton 25

26 MIND S REACTION TO PAIN The MIND: This is too much. I can t deal with this pain. They have it so much better than me. I m such a failure! Why do I have to get pain? I don t think I can make it. A1-B1: Hamilton 76 Cognitive Fusion STORIES. A1-B1: Hamilton 77 Fusion Why me. I can t live with pain! I can t live without pain killers! I m weak I m defective. I m a loser A1-B1: Hamilton 78 A1-B1: Hamilton 26

27 Defuse from thoughts with Mindfulness A1-B1: Hamilton 79 EXERCISE: NOTICE Thoughts Cognitive Defusion (Hayes, Strosahl) With awareness clients can begin to observe the storyteller and choose if it is helpful in the moment to believe the storyteller. A1-B1: Hamilton 81 A1-B1: Hamilton 27

28 Acceptance (Hayes, Strosahl) Acceptance means: to take what is offered. It s the opposite or flipside of avoidance. The willingness to experience whatever is taking place in the present moment. A1-B1: Hamilton 82 Key Targets for Acceptance (Hayes, Strosahl, Walser) Assist clients: Ø Let go of the agenda of control as applied to internal experience. Ø See experiential willingness as an alternative to experiential control. A1-B1: Hamilton 83 Being Present (Hayes, Strosahl) ACT promotes effective, open, and undefended contact with the present moment. A1-B1: Hamilton 84 A1-B1: Hamilton 28

29 Being Present (Hayes, Strosahl) Ø Clients are trained to observe and notice what is present in the environment and in private experience. Ø Clients taught to label and describe what is present, without excessive judgment or evaluation. A1-B1: Hamilton 85 Being Present (Hayes, Strosahl) Contact with the present moment can also include behavioral and cognitive exposure techniques. (Being with a craving, pain) *****However, exposure techniques are not done with the purpose of extinguishing or diminishing emotions, sensations A1-B1: Hamilton 86 VALUES A1-B1: Hamilton 29

30 Values (Dahl, Plumb, Stewart, Lundgren) Values provide a context in which a client may be more willing to experience difficult thoughts/ feelings as she moves in valued directions. A1-B1: Hamilton 88 Committed Action (Hayes, Strosahl) Ø Once the barriers of avoidance and fusion are more recognizable Ø and a general direction (values) for travel is defined, Ø making and keeping commitments becomes useful. A1-B1: Hamilton 89 Mindfulness Exercise Awareness of Sounds: Ø Sit in comfortable position Ø Close eyes or focus on point in room Ø Pay attention to sounds that appear (2 minutes) Ø Note any thoughts, feelings, sensations that arise and return to noticing sounds Ø Discuss what client noticed, experienced A1-B1: Hamilton 90 A1-B1: Hamilton 30

31 Mindfulness Exercises Ø Awareness of senses: l Sounds l Sight l Body Sensations l Taste (Raisin) Thought labeling Breath Mindful session A1-B1: Hamilton 91 Defusion Exercises Metaphors: Ø How many in the session? Ø Bus Exercise Ø Monsters on the Ship Ø Battle Field Ø Chess Board Ø The Thought Box A1-B1: Hamilton 92 Ø Workability, costs ACT Language Ø Willingness vs struggle Ø Meaningful life, vitality Ø Valued-direction Ø Toward/away from what s important to you Ø Notice A1-B1: Hamilton 93 A1-B1: Hamilton 31

32 Acceptance Exercise Body Scan Notice sensation & study it as if you are a curious scientist : l Shape l Size l Surface- smooth, rough l Soft, hard, solid l Temperature l Color l Moving or still A1-B1: Hamilton 94 MOVEMENT EXERCISES LIFELINE MATRIX A1-B1: Hamilton 95 A1-B1: Hamilton 96 A1-B1: Hamilton 32

33 The Matrix (Kevin Polk, 2011) Ø Where do you want to go? (Values) Ø What does your mind have to say about this? (thoughts, feelings, sensation) Ø Struggle vs. Willingness. A1-B1: Hamilton 97 On White Board. Where did you want to go? Attend my class. Thoughts/Stories: I know it won t work. I won t be able to sit that long. Led to? I didn t go. A1-B1: Hamilton 98 Questions? Comments? A1-B1: Hamilton 33

34 The ACT Community ACT Membership ACT Intensive Trainings ACT World Conferences Berlin-July 14-19, 2015 ACT Network, SIGs (Pain SIG) A1-B1: Hamilton 100 Contact Info: Julie Hamilton, LMSW, ACSW, CAADC Bingham Farms, MI A1-B1: Hamilton 101 Bibliography Dahl, J. C., & Lundgren, T. L. (2006). Living Beyond Your Pain: Using Acceptance and Commitment Therapy to Ease Chronic Pain. Dahl, J., Wilson, K. G., Luciano, C., & Hayes, S. C. (2005). Acceptance and Commitment Therapy for Chronic Pain. Reno, NV: Context Press. [Describes an ACT approach to chronic pain. Very accessible and readable. One of the better clinical expositions on how to do ACT values work.] A1-B1: Hamilton 102 A1-B1: Hamilton 34

35 Bibliography McCracken, L. M. (2005). Contextual Cognitive- Behavioral Therapy for chronic pain. Seattle, WA: International Association for the Study of Pain. [Describes an interdisciplinary ACT-based approach to chronic pain] A1-B1: Hamilton 103 Bibliography: S. Hayes. Get out of your Mind and Into Your Life, S, Hayes, et al, A Practical Guide to Acceptance and Commitment Therapy, S. Hayes, K. Wilson, et al. Acceptance and Commitment Therapy, S. Hayes, et al, Relational Frame Theory: A Post Skinnerian Account of Human Language and Cognition, G. Eifert, J. Forsyth. Acceptance Commitment Therapy for Anxiety Disorders, A1-B1: Hamilton 104 Bibliography: M. Linehan, et al, Mindfulness and Acceptance: Expanding the Cognitive-Behavioral Tradition, S. Hayes, et al, Learning ACT: An Acceptance & Commitment Therapy Skills Training Manual for Therapists, S. Hayes, K. Strosahl, et al, A Practical Guide to Acceptance and Commitment Therapy, S. Hayes, et al, Mindfulness and Acceptance for Addictive Behaviors, A1-B1: Hamilton 105 A1-B1: Hamilton 35

36 Bibliography: R. Harris, The Happiness Trap, R. Harris, ACT Made Simple, 2009 J. Dahl, et al, The Art & Science of Valuing in Psychotherapy, K. Wilson, Mindfulness for Two: The Acceptance and Commitment Therapy Approach to Mindfulness in Psychotherapy, K. Strosahl, P. Robinson, Inside This Moment, 2015 A1-B1: Hamilton 106 A1-B1: Hamilton 36