Pain Management Center

Psychological Services (book excerpts)

The following articles are excerpts from are from the book Mastering Chronic Pain: A Professional's Guide to Behavioral Treatment. by BW Pain Management Center physician Dr. Robert N. Jamison, Ph.D., published by Professional Resource Press, Sarasota, FL, 1996.

• Interdisciplinary Pain Management Program
  

  Interdisciplinary pain management programs have been shown to be more effective than unimodal approaches. Flor, Fydrich, and Turk (1992), in a meta-analysis of outcome data from 65 studies, found that 1) combined treatments are superior to single treatments or no treatments for chronic nonmalignant pain; 2) participation in an interdisciplinary pain program increases the return-to-work rate (average, 43%) and decreases health care utilization; 3) the benefits of an interdisciplinary pain program are maintained over time; and 4) patients who benefit from treatment and those who do not are similar in terms of age, pain duration, workers' compensation status, and treatment duration.

  Goals of the program

  At the start of a program, each patient should identify specific goals. These may include the following:

  1. Reduction of pain intensity. Although patients rarely if ever report that their pain has been eliminated, by the conclusion of the program they often report a reduction in the amount of pain. Most patients enter a pain management program because of persistent pain, but they are taught not to set pain elimination as their primary goal. Instead they are encouraged to focus on other, more attainable goals.
     
     
  2. Enhancement of physical functioning. In group-based pain programs, patients are encouraged to participate regularly in exercise (including stretching, cardiovascular reconditioning, and weight training) and to increase their activity at a progressive rate under supervision. The goal is to gradually increase function without exceeding predetermined limits of pain and discomfort. Patients have been known to increase their physical strength and endurance by 50% - 100% over a three-month period.
     
     
  3. Proper use of medication. Through education and daily monitoring, most patients are able to use prescription pain medication responsibly. Participants are frequently asked to monitor their medication for a week before entering a program and to report their daily medication at the end of the program.
     
     
  4. Improvement of sleep, mood, and interaction with other people. Most patients report being depressed and having problems relating to other people. At the conclusion of most group-based pain programs, patients usually show evidence of improved sleep, decreased emotional distress and increased self-esteem.
     
     
  5. Return to work or to normal daily activities. Patients who set as their goal an eventual return to work are often successful. Follow-up helpfulness ratings indicate that patients who have a positive experience in a pain management program tend to return to work and/or maintain an active, productive lifestyle.

  Roles of a multidisciplinary team

  Chronic pain involves a complex interaction of physiological and psychosocial factors, and successful intervention requires the coordinated effort of a treatment team with expertise in a variety of therapeutic disciplines. Although some pain centers offer a unimodal treatment approach, most programs use a blend of medical, psychological, vocational, and educational techniques. Generally included are medical assessment, medication management, pain-reduction treatments, didactic instruction, relaxation training, biofeedback, physical therapy, psychotherapy, and vocational counseling.

  Most interdisciplinary pain treatment programs have as their core staff one or more physicians, a clinical psychologist, and a physical therapist. Other health professionals who may play important roles include clinical nurse specialists, occupational therapists, vocational rehabilitation counselors, and exercise physiologists. Physicians from specialty areas (e.g., neurology, rheumatology, orthopedic surgery, physical medicine, internal medicine) should be available for consultation. The physician's primary responsibility is to oversee the medical aspects of treatment and to prescribe medication and procedures when needed. The psychologist, psychiatrist, or social worker addresses the mental health and behavioral aspects of the patient's program. He or she may facilitate the pain management classes and group therapy sessions and may offer training in biofeedback and relaxation. The physical therapist and exercise physiologist coordinate daily group exercises and assist patients in setting up and following individual exercise programs. An interdisciplinary staff coordinates efforts to rehabilitate the patient and designs a comprehensive discharge and follow-up plan to meet each patient's short- and long-term needs. The patient's participation is strongly encouraged. Among the predictors of success in a multidisciplinary pain program are the patient's motivation to cope with pain and the patient's support system outside the program.

  Program structure

  Multidisciplinary pain programs are often highly structured, time limited, and organized along a specific treatment schedule. Common goals include an increase in physical, social, and emotional functioning and a decrease in pain and in reliance on health care services. The patient is expected to attend clinic sessions and to participate in all aspects of the program. These expectations must be made clear. To this end, patients frequently sign a treatment contract that spells out the general program requirements as well as individual treatment goals. In addition to helping patients understand exactly what is expected of them, such a contract is a means of identifying before treatment those patients who may lack motivation or have difficulty conforming to the structure of the program. Patients are asked to keep a daily written record of their pain intensity, medication use, and activity levels. Noncompliance may be grounds for discharge from the program.
  
  
  

• Cognitive Therapy in Pain Management
  

  Cognitive/behavioral therapy has a number of objectives. The first is to help patients change their view of their problem from overwhelming to manageable. Patients who are prone to catastrophize benefit from examining the way they view their situation. What has been perceived as a hopeless condition can be reframed as a difficult yet manageable situation over which the patient can exercise some control.

  The second objective is to convince patients that their treatment is relevant to their problem and that they must be actively involved both in that treatment and in their rehabilitation. They need to understand how relaxation training, cognitive restructuring, adaptive coping skills, and pacing behaviors can help decrease their pain. Patients must reorient their view away from that of passive victim to that of proactive, competent problem solver. When individuals are successful in managing painful episodes, their views change. They eventually begin to believe themselves capable of overcoming any acute flare-up of pain.

  The third objective is to teach patients to monitor maladaptive thoughts and substitute positive thoughts. Persons with chronic pain are plagued, either consciously or unconsciously, by negative thoughts related to their condition. These negative thoughts have a way of perpetuating pain behaviors and feelings of hopelessness. Learning how and when to attack these negative thoughts and to substitute positive thoughts and adaptive management techniques is an important component of cognitive restructuring. Patients must be encouraged to attribute success to their own efforts; they need to feel that they are responsible for the gains they make. Finally, problems and lapses need to be discussed so that the patient will have an advance "game plan" to manage short-term setbacks.

  Most chronic pain patients need support in maintaining their gains. Important aspects of contingency management include 1) giving specific homework assignments, 2) offering appropriate examples to patients, 3) helping to organize a daily routine and schedule, 4) recruiting support from family members, 5) encouraging outside activities and involvement, 6) linking the patient to appropriate resources, 7) monitoring progress and, 8) actively following patients after treatment.

  One way patients actively participate in a pain management program is through regular monitoring of their own progress. By recording data on their pain intensity, activity levels, moods, and medications, participants gain a better understanding of their condition and of the factors that impact it. Regular monitoring takes time and effort but offers insights. Therapists should regularly inspect patients¹ forms and questionnaires to obtain up-to-date information and to underscore the importance of completing these documents.

  Unfortunately, the progress made over the course of a structured program is sometimes reversed within six months. This outcome is inevitable for some proportion of the participants in any program designed to change behavior. A way to prevent relapse is to offer a structure for follow-up, possibly including individual sessions with the group facilitator and meetings with regular support groups.
  
  
  

• Vocational Rehabilitation for Chronic Pain Patients
  

  The goal of vocational rehabilitation is a return to work. After an extended period out of work, chronic pain patients become both physically and psychologically deconditioned to the demands and stresses of the workplace. In a pain management program, some time should be allotted to the discussion of back-to-work issues in a group setting. If possible, a vocational rehabilitation counselor should attend the group session and share information on resources with the members. Together, a vocational rehabilitation counselor and a patient can develop an individualized plan that incorporates both long-range employment goals and short-term objectives based on medical, psychological, social, and vocational factors. Vocational rehabilitation counselors are specialists in the assessment of aptitudes and interests, transferable skills, physical capacity, modifications in the workplace, skills training, and job readiness.

  The number of recorded work-related disabilities has increased dramatically over the past thirty years. The return-to-work statistics are alarming. Chronic pain patients who have been out of work for longer than a year have an estimated chance of ever returning to full-time employment of <3%; those who have been out of work for longer than two years have <1% chance of ever working again. Insurance carriers are interested in the rehabilitation of these patients because of the enormous expenses they incur. An estimated 5% of all workers' compensation claimants account for 85% of the disability funds distributed. Unfortunately, many patients do not know what options they have for return to work. It is helpful to review what a vocational rehabilitation counselor does and to help group members understand what is involved in a return-to-work determination.

  Many chronic pain patients receive workers' compensation benefits or social security disability income. These patients may fear that their benefits will be jeopardized if they return to work. A vocational rehabilitation counselor can help a patient negotiate with an employer a return-to-work trial that will not jeopardize the patient's income.

  For example, the counselor can arrange with an employer to hire the patient for a specific period (e.g., three months) during which the employee's productivity will be evaluated. The employer agrees to pay the employee reduced wages that will not jeopardize workers' compensation. In addition, the employer agrees to train the individual and, at the conclusion of the work period, either to hire the individual full time or to write a letter of reference. In this way the patient gains work experience with a letter of reference without jeopardizing disability benefits. Advantages to the employer include the performance of work at lower wages with no obligation to hire on a permanent basis. The vocational rehabilitation counselor acts as a mediator in getting the chronic pain patient "in the door" of a business - and eventually, perhaps, back to work.

  One common misconception is that persons receiving compensation benefits are lazy and are not interested in working. In fact, most people on disability leave wish that they were working. In our society work is a valuable part of who we are. We all have a need to accomplish things and to feel useful. Although many chronic pain patients may not have the option of returning to their former place of employment, they should be encouraged to explore other full-time, part-time, or volunteer work opportunities. Patients should become familiar with the Americans with Disabilities Act (A.D.A.) so that they know their rights regarding discrimination due to a pain-related disability. The central theme of the A.D.A. is that a disability that does not interfere with job performance cannot be used to reject applicants. In addition, employers are required to make accommodations for persons with disabilities so that they can work. An outline of the A.D.A. is presented in the appendix of the patient's handbook.

  Local vocational resources should be discussed with the group. Patients may find it useful to have, for instance, information on the Job Training Partnership Act (with specific data on state and local funding), veterans programs that help people return to work, and the vocational services offered by the Division of Industrial Accidents.

  Patients may not be aware of one employment advantage of persons with disabilities: some large corporations receive tax credits for disabled employees. Thus, individuals with chronic pain may want to consider contacting the disability/equal opportunity office of a corporation rather than the personnel department to improve their chances of being hired.

  A vocational rehabilitation counselor can outline various aspects of the rehabilitation process. The components may include a vocational assessment, a transferable skills analysis, a physical capacity evaluation, a work disability assessment, a job analysis, and an employment readiness determination. Research shows that individuals are more likely to return to work if they believe that they will. The therapist should refer persons who believe that their chances of returning to full-time employment are >50% for a vocational rehabilitation functional capacity test.

  
  

• Program Evaluation in Pain Medicine
  

  There has been a rapid change in the way health care services are offered in the United States. More and more decisions about treatment are made by employees of insurance carriers on the basis of financial resources rather than need. "Managed care" favors structured, group-based programs because they are time-limited and economical to run. However, the increasing need for accountability and efficacy has encouraged the implementation of cost-saving measures and ongoing evaluation. Preference is given to programs that are of demonstrated efficacy and are tailored to the individual (e.g., not all participants receive every treatment).

  Program evaluation improves the use of resources, organizes data for marketing, and helps managers decide which direction a program will take. Effective program evaluation reports offer data to assist top level administrators to create solutions for poor outcome, increased costs, and decreased market share. The goals of program evaluation in chronic pain management programs are to increase the benefits to persons the program serves, increase program productivity, and improve market position.

  An important component of any group-based pain program is its ability to measure its own effectiveness. A number of recommendations for effective program evaluation have been put forward by the Commission on the Accreditation of Rehabilitation Facilities (CARF). Each program should have a mission statement, and lists detailing admission criteria, services offered, specific objectives, the priority of each objective, expectations regarding minimal and optimal goals, objective measures of performance, the period to which these measures apply, and the way in which information collected is documented.

  A system should be in place for obtaining follow-up information from patients on the use of medications, the use of health care services, return to gainful employment, functional activities, the ability to manage pain, and the subjective intensity of pain. This system should include a schedule for periodic contact with the patient after discharge, and a data base containing information updated on a regular basis. This type of system helps determine how a program meets the needs of individual patients and of participants overall.

  Program evaluation should encompass goals and objectives that are achievable and end results that are measurable. Each program evaluation system should include objectives and measures for 1) productivity of patients (e.g., return to work), 2) heath care utilization (e.g., reduction in physician visits), 3) activity level (e.g., increased walking and exercising), 4) medication usage (e.g., adherence to AMA guidelines for proper use of medications), 5) program costs (e.g., maintenance of estimated and actual costs per patient at a steady level), 6) program productivity (e.g., a low ratio between the number of staff hours devoted to the program and the number of patient hours), 7) patient helpfulness ratings (e.g., above average ratings of helpfulness for all services rendered), 8) pain coping and emotional adjustment (e.g., decreased ratings on the Beck Depression Inventory before and after treatment), 9) medical findings (e.g., improvement in objective physical measures, such as range of motion), and 10) socialization and activities of daily living (e.g., improved scores on the Sickness Impact Profile). A program evaluation report should include primary objectives, measures, time of measurement, source of information, and expectations as well as outcomes. Finally, program evaluation should help identify which services are most effective in the treatment of chronic pain patients.

  Additional components of a program evaluation system include 1) follow-up data from a representative sample of patients, 2) valid and reliable dependent measures standardized for persons with pain, 3) a comparison of post-treatment and follow-up data, and 4) assessment of individual differences.