A Mindful Approach to Pain Management · Treatments for pain management are all too often unsuccessful. A1-B1: Hamilton 10 Current Data NIDA 2011 Ø For moderate to severe pain prescribed

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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.

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Where do we begin?

LAUGHING BABY

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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.

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Cost of Pain

And what does it cost young

people physically, emotionally, spiritually?

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MI-Youth Overdoses

Ø Youth overdoses almost quadrupled in Michigan from 1999-2001 to 2011-13.

Ø Michigan’s overdose death rate is higher than the national average for youth ages 12-25.

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

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•  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 2012.

•  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

A Profile of Drug Overdose Deaths Using the Michigan Automated Prescription System

(MAPS)

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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)

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Treatment Kabot-Zinn, 2011

Treatments for pain

management are all too often unsuccessful.

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Current Data NIDA 2011

Ø For moderate to severe pain prescribed opioid analgesics are first line of treatment.

Ø 2002-2010 opioid sales per capita up 600%

Ø Prescribed opioid OD’s higher than heroin/cocaine combined

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Trends Over Last 15-20 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

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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

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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

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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.

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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.

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Chronic Back Pain (Dahl, et al., 2005)

Research shows much confusion:

§  Pain is much more complex than just physical pathology….

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When a young client comes in with complaints of chronic pain….

…..what goes through your mind?

….what feelings show up?

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What do clients dealing with pain want to see

happen when they seek treatment?

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Ø Efforts to control, eliminate (pain “killers”)

Ø Behavioral changes Ø Life style changes Ø Thoughts, beliefs about

themselves Ø Self-stigmatization

What has the client gone through with pain by time they enter treatment with us?

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Approaches Assist Clients with PAIN

Ø CBT Ø Mindfulness Based Stress

Reduction Ø ACT: Acceptance and

Commitment Therapy (Psychological Flexibility)

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Experiential Avoidance

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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.

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A serious pain problem/diagnosis is not something that is easy to hear or think about…a permanent pain

diagnosis is worse news yet.

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However, an unwillingness to

remain mindful of the pain/stress symptoms can have serious

consequences.

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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:

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Such as: Ø  Doctors Ø  Medications Ø  Symptoms Ø  School-events Ø  Social activities Ø  Physical movements that previously precipitated

it

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Emotions

Avoidance Physical Pain

Cognition

Pain and Suffering

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Any efforts to NOT think about pain

and its associations triggers us to think about….

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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.

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Experiential Avoidance

Is it GOOD or BAD to avoid and/or control pain?

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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

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MIND

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The Mind

Ø Analyzes Ø Evaluates Ø Predicts Ø Plans Ø Judges Ø Compares Ø Remembers

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Avoid and Control Pain

CLEAN vs. DIRTY

Reactions

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Avoid and Control Pain

The Mind as a Story Teller…

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PAIN-FUL STORIES

Ø  Injured runner story…. Ø Other PAIN-full stories…

Conceptualized Self vs. Self as Context

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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

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New Wave of CBT Treatment:

Most of these are used for mental

health, addiction and pain management.

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“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.

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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

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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 (self-

compassion) §  Reframing the personal meaning of

what’s there (aka – expanding) Strosahl and Robinson, 2015

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Traditional CBT

Ø Effective…on the short term Ø Symptom reduction Ø Controlling repertoire Ø Thought Stoppage

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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).

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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).

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“….and the inclusion of these methods does not appear to reliably increase the effectiveness of treatment.” (Smeets, Vlaeyen, Kester, & Knottnerus, 2006).

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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, self-efficacy, readiness to change, threat appraisals) are distinct from or serve to influence one another. (Vowles, Wetherel, Sorrels, 2008)

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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)….

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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

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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.

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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.

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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 whiplash-associated disorders (WAD)? A

randomized controlled trial. Cognitive Behaviour Therapy, 37(3), 1-14.

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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)

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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.

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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

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What is ACT…… ACT is: 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

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What is ACT……

ACT can: 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.

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“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  www.contextualscience.org

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ACT and Pain (Hayes, et al, 2011)

Functional Analysis- 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:

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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)

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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, self-mutilation, 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)

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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.)

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“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 “self-stories,” then redirect their attention to the present moment, i.e., through mindful breathing or another variation of mindful exercise.

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“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.

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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.

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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.

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This includes pain in all its forms…

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ACT in a Nutshell…

Ø AWARENESS (mindfulness) Ø ACCEPTANCE/WILLINGNESS

(making room for pain) Ø VALUED Directed Behavior

(Action!)

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Today’s Exercises

Completely voluntary…..

“…..Are you willing?”

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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

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Thought Stoppage?

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ACT (Russ Harris)

The aim of ACT: Ø To lead a rich, full, and

meaningful life based on one’s values…

Ø While accepting the PAIN that goes with it.

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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…

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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.”

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Cognitive Fusion

STORIES….

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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…”

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Defuse from thoughts with…

Mindfulness

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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”.

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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.

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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.

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Being Present (Hayes, Strosahl)

ACT promotes effective, open, and undefended contact with the present

moment.

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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.

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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…

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VALUES

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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.

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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.

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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

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Mindfulness Exercises

Ø Awareness of senses: l  Sounds l  Sight l  Body Sensations l  Taste (Raisin) Thought labeling Breath Mindful session

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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

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ACT Language

Ø Workability, costs Ø Willingness vs struggle Ø Meaningful life, vitality Ø Valued-direction Ø Toward/away from what’s important to you Ø Notice

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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

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MOVEMENT EXERCISES

LIFELINE

MATRIX

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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….

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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.”

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Questions? Comments?

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The ACT Community

www.contextualscience.org 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 48025 [email protected] www.mindfullives.com 248-549-4197

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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.]

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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]

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Bibliography: S. Hayes. Get out of your Mind and Into Your Life,

2005. S, Hayes, et al, A Practical Guide to Acceptance

and Commitment Therapy, 2004. S. Hayes, K. Wilson, et al. Acceptance and

Commitment Therapy, 1996. S. Hayes, et al, Relational Frame Theory: A Post

Skinnerian Account of Human Language and Cognition, 2001.

G. Eifert, J. Forsyth. Acceptance Commitment Therapy for Anxiety Disorders, 2005.

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Bibliography:

M. Linehan, et al, Mindfulness and Acceptance: Expanding the Cognitive-Behavioral Tradition, 2004.

S. Hayes, et al, Learning ACT: An Acceptance & Commitment Therapy Skills Training Manual for Therapists, 2007.

S. Hayes, K. Strosahl, et al, A Practical Guide to Acceptance and Commitment Therapy, 2004.

S. Hayes, et al, Mindfulness and Acceptance for Addictive Behaviors, 2012.

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Bibliography:

R. Harris, The Happiness Trap, 2008. R. Harris, ACT Made Simple, 2009 J. Dahl, et al, The Art & Science of Valuing

in Psychotherapy, 2009. K. Wilson, Mindfulness for Two: The

Acceptance and Commitment Therapy Approach to Mindfulness in Psychotherapy, 2009.

K. Strosahl, P. Robinson, Inside This Moment, 2015

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A Mindful Approach to Pain Management · Treatments for pain management are all too often unsuccessful. A1-B1: Hamilton 10 Current Data NIDA 2011 Ø For moderate to severe pain prescribed

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