edmund a. o’connor, jr., ph.d. director & chief psychologist the pain center at (616) 233-3480...
TRANSCRIPT
Edmund A. O’Connor, Jr., Ph.D.Director & Chief Psychologist
The Pain Center at
(616) 233-3480
Using Creative Hopelessness to Break the Treatment Failure Cycle
Acceptance & Commitment Therapy
“The single most remarkable fact of human existence is how hard it is for human beings to be happy.”
“Suffering is a basic characteristic of human life.”
There is an assumption that there is a healthy normality
Language is at the core of human suffering
Goal: to interact differently with pain and what our mind tells us
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What is “Acceptance”?
Living in the present moment
Pursuit of valued life activities in the presence of pain Lack of negative thoughts and
emotions
Willingness to remain in contact with and actively experience both good and bad private events
Optimism during pain
Good pain coping skills Optimism regarding the future
A sense of control over pain
Recognizing pain may not change, therefore a change in life is needed
Not needing to avoid or control pain
Recognizing that the suffering may not change
What’s the Goal of Treatment?
“eh!”
StressAnxiety
Depression
Disability
Values
Vitality
IntimacyProductivity
Traditional Medical & Psychological Models
Acceptance & Commitment Therapy
Fear of future health and finances; loss of past health and function
ACT and Chronic Pain
Pain avoidance & struggle for
control
Strong belief in negative and
catastrophizing thoughts
“ I am a pain sufferer” & all that goes with it
Pain focus; lose sight of
values
Efforts to control pain
dominate at the expense of
valued action
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ACT and Chronic Pain
Pain avoidance & struggle for
control
Strong belief in negative and
catastrophizing thoughts
“ I am a pain sufferer” & all that goes with it
Pain focus; lose sight of
values
Efforts to control pain
dominate at the expense of
valued action
Acceptance of pain and emotions …
willingness to feel and
experience
Defusion
Detach from painful thoughts and emotions
Psychological Flexibility
Self as Context
Pain is only a small part of who I am
Committed Action
Behavior reflects values
Values
Clarity of what is
meaningful
Fear of future health and finances; loss of past health and function
Contact with the present moment
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ACT is … "What we've been talking about is kind of like the show
"Fear Factor." The stuff that the contestants do on that show are really crazy. No one would every jump off a bridge or eat a bunch of cow intestines for no reason. It wouldn't make any sense to put yourself through all that pain. But it's a different story when you could get a million dollars for it. These people actually choose all that pain and yuckyness because it could be worth a bunch of money. I guess that's what living according to my values is like. I might choose to be in pain for the things that matter to me."
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Failed Treatment Cycle
What does it look like?
Why does it keep going?
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“The more our health care system helps us to avoid unpleasant feelings, the less we tolerate them, the more we believe it is abnormal to have them, and the more we do.”
Dahl & Lundgren, 2005
Failed Treatment Cycle
"Ill health is abnormal and unnatural. Health is your birthright and the normal, natural state of your body."
Yours in Health,
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Failed Treatment Cycle
The biggest reason - we are taught discomfort is bad, so we treat it as we would genuine illness “It is how the person reacts to the symptom, rather than
the symptom itself that determines health seeking behavior, disability and sick-listing”
“It is not that pain itself has increased—rather our willingness to accept pain that has decreased.” Why the shift? Pain used to be unavoidable, and thus
was accepted, now we can avoid it better, so we don’t learn to tolerate it
We keep trying to control our pain
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Pain ReliefPain Willingness
Acceptance of the Unworkability of Control
95% solutions When I get rid of pain, I can have “X”
Why we stick with it It works elsewhere It seems to work for others
“My friend had this surgery and …” You are told it should work for you
Repeatedly try medications, PT, shots, etc. “I don’t know why you still have pain.” “It’s all in your head.”
It even SEEMS to work short run Drugs work ... But at what cost? Patients care about pain right now
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Acceptance of the Unworkability of Control
“If you don’t want it, you got it.” Metaphors
Tug of war with a monster Feed the tiger Chinese finger trap
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Acceptance of Where You Start: “Creative Hopelessness”
Not a feeling. Context from which futile struggles are seen for what they are and behavioral change is possible.
The client’s first exposure to all six ACT processes and the ACT therapeutic stance Assessment of ACT targets Examine workability Validate the client’s experience
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Can range from almost psychoeducation to gut wrenching processes of clearing the field for a person who is deeply stuck
Key questions: How has that worked for you? It must be genuine! How has that worked long term? Where has it worked / not worked? Is this familiar? Have you tried that before? Is your life bigger or smaller? Does this seem like a “rigged game”?
Creative Hopelessness: How To
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You’ve tried about everything Suppose your experience is valid? Suppose it
won’t work Metaphors
Man in the hole Looking in the fridge
Desire to control keeps showing up Dig stairs, etc. Oyster pearl
Acceptance of Where You Start:
“Creative Hopelessness”
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Pain Treatment Experience
Do not judge or encourage Refer back to long-term effects when
they seek to go down the same path
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Type of Pain Treatment
Short-term effects on pain
Long-term effects on pain
Long-term effects on Quality of Life
Meds some relief None Couldn't teach
Surgerytotal relief for a
short time NoneGreat for a while, now back where I started
Alcohol some relief NoneSick every morning;
wife is mad
In your reactions subtly cast the issue in experiential avoidance terms – What are they trying not to feel?
Admit partial success of control efforts; go small if full success is claimed; tie back to QOL
Be careful not to get hooked by content (agreement; disagreement; need to understand; shifting topics; attacks, etc.)
Sign of progress – silence, humor, starts and stops, lightness
Creative Hopelessness: How To
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Remain curious. Hold assumptions of experiential avoidance lightly. Avoid convincing, no attempts to prove pain avoidance is the
problem
Don’t get caught up in content.
Sit with uncertainty and confusion.
Watch for picking up the shovel.
Remain on equal ground and focus in the moment.
Creative Hopelessness: How To
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Great! They’re Hopeless … Now What?
Identify what they value “What do you really want?” “If pain weren’t an issue, what would you be
doing?” “Why?” (Why gets at value) Attending Retirement Party or Funeral
Can they be willing to bring pain along to get what they value?
Watch for avoidance and fusion It will show up
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Great! They’re Hopeless … Now What?
Match treatment to values How will drugs (or surgery, or …) get you
“(value)”? Watch for attempts to control Sadness in effort is ok ... It is hard!
Refer when: Truly hopeless Cannot identify values Heavily invested in what their mind tells them
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“So what can I do?” Prioritize valued living
Discuss side-effects and pain management in terms of cost to valued activities
Avoid “You need to accept it”
Enlist patient commitment to valued function as a priority because it is what they want most (i.e., if you didn’t have pain – what would you be doing?)
Honesty about hopelessness
Avoid pain relief as the primary goal unless it is acute and realistic At least tie them into
pursuit of values Control the controllable
Normalize pain flare-ups Refer those who are
stuck or trapped in dysfunctional thinking and distress
Committed Action What I value is …
“Closeness with my wife and kids”
What I’ve been doing is … “Checking-out, lying in bed or in front of TV”
What it cost me is … “My family. How can I have a relationship like that?”
“I am through with that”
My commitment is … “Have dinner with my family, no matter how I feel … I miss them”
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