Is It Time to Talk About Managing Pain Without Opioids?

Opioids are certainly in the news. The US Surgeon General recently issued a statement on the relationship between their widespread use for chronic pain and the subsequent epidemics of opioid addiction and accidental overdose (US Surgeon General, 2016). The US National Institute for Drug Abuse and Centers for Disease Control have also issued concerns (see here and here, respectively). Mainstream media reports on the problems of opioids appear almost daily.

After a couple of decades of strong proponents and persistent messaging on the benefits of opioids, the tide of public opinion and the opinion of health experts seems to be turning against the widespread use of opioids for chronic pain.

Among people with chronic pain who use opioids, this change in perspective on the use of opioids can be alarming. For about two decades, people with chronic pain have been encouraged to take opioid medications. Many have subsequently come to rely on them. Some may have even come to believe that it is impossible to manage chronic pain well without the use of opioid medications.

We now face a dilemma in the management of chronic pain. We have strong managing pain without opioidsproponents for the use of opioids and strong proponents against the use opioids. Both sides have valid concerns that lead to their respective positions.

Often, the sides in this dilemma seem to get expressed in untenable ways. It’s as if the stakeholders in the field have to choose between two bad options: either you take opioids on a chronic basis and expose yourself to the risks of addiction and accidental overdose, which are actually occurring to people with chronic pain at epidemic proportions; or don’t take opioids, remain safe from addiction and accidental death, but expose yourself to pain, which may be intolerable. Healthcare providers seem to face a corresponding dilemma: either manage patients on chronic opioids while exposing them to addiction and accidental overdose or refrain from opioid management and expose them to what might be intolerable pain. Whether patient or provider, both options seem bad.

Is there a third option?

There is another way, of course. It’s called chronic pain rehabilitation and it effectively shows people how to successfully self-manage chronic pain without the use of opioid medications. Chronic pain rehabilitation clinics have been around for three to four decades. However, it’s hard to get people to go to them. It’s not because they are ineffective. Research over the last four decades shows clearly that they are effective (Gatchel & Okifuji, 2006; Kamper, et al., 2015).

Managing pain without opioids

People who’ve been managing their pain with opioids are often a little leery of recommendations to go to a chronic pain rehabilitation clinic. The recommendations seem to run counter to much of what’s been previously recommended throughout the long course of care for their chronic condition. After years of recommendation and encouragement to take opioids by some providers, it’s hard to understand why other providers might recommend and encourage the exact opposite. Maybe they are recommending learning to self-manage pain without the use of opioids because:

  • They don’t believe my pain is as bad as it is.
  • They think (wrongly) that I’m addicted to opioid medications.
  • They think my pain is all in my head.
  • They just want to make money off their program that they are recommending.
  • They are ignorant of what’s most effective for chronic pain (i.e., they don’t know what they’re talking about).
  • They are not as compassionate as the previous providers who recommended opioid management.

In all these concerns, people become leery of a recommendation to forego opioids because it’s hard to believe that the recommendation is being made in the best interest of the patient. It seems that relief of pain through the use of opioids is what’s best for the patient and anything that runs counter to that recommendation must be in the best interests of someone else.

Moreover, it’s a sensitive topic. Let’s face it, no one feels especially proud of managing their chronic pain with opioids. Rather, people with chronic pain do it because it seems a necessity – they believe that the pain will be intolerable without opioids. The recommendation and encouragement to take opioids by healthcare providers and by society, more generally, is helpful in this regard. Such encouragement supports the decision to use opioids, one in which there’s always been some ambivalence. Again, no one is exactly proud of taking opioids for chronic pain; upon reflection, there is always some degree of doubt or concern about their use that leads to a sense of vulnerability and sensitivity. It’s helpful to have others, especially healthcare providers, recommend and encourage their use.

When, however, other healthcare providers recommend against opioid use and encourage learning to self-manage pain instead, it can sting because it taps right into the inherent sense of vulnerability and sensitivity that occur when taking opioids.

It’s hard to see a healthcare provider as acting in the best interest of patients when they openly question the issue that can be so sensitive. The recommendation to learn to self-manage pain without the use of opioids shines a direct light onto the inherent sense of vulnerability or shame that so many feel when using opioids for the management of chronic pain.

tapering opioidsThe recommendation inadvertently breaks all the tacit rules that healthcare providers (and pharmaceutical companies) have heretofore been following. The rule up until now has been to reassure patients that it’s okay to take opioids for chronic pain. Over the last two decades, the field has asked patients to trust these assurances that they shouldn’t be ashamed of their need for opioid medications. Now, the field is changing and has begun to question the need for opioids. In so doing, we break the trust of patients who have been on opioids for some time: we expose them to potential pain, but also the shame that heretofore we alleviated with assurances that taking opioids is okay. It’s no wonder that patients are now upset.

In a microcosm, it’s this dynamic that occurs in the offices of chronic pain rehabilitation clinics everyday when, after the initial evaluation and recommendation to participate in the therapies of the clinic occurs, patients leave and refrain from accepting the recommendation to learn to self-manage pain. Such patients are doubtful that it will work and are afraid of the pain that would ensue if it doesn’t. Moreover, though, they tend to leave feeling somewhat ashamed that the provider so openly talked about the fact that they could learn to self-manage pain without the use of opioids. Providers are supposed to provide reassurance that it’s okay to be on opioids, not question their use.

Even when it’s well-informed and done in the best interest of the patient, the recommendation and encouragement to learn to self-manage pain without the use of opioids can be heard as a subtle yet stinging rebuke because of the inherent sensitivity that occurs when taking opioids for chronic pain.

How, then, do we bridge this divide?

The Institute for Chronic Pain has a new content page that may play a small role in such bridge building. When patients come to chronic pain rehabilitation clinics for the first time, they may have never had an experience of a provider talk to them about self-managing pain without the use of opioids. As we’ve seen, it’s a complex and sensitive interaction that occurs under the surface of the words that are spoken. It can be a lot to take in. It can feel like the rules are being broken. As we’ve seen, it can be easy to become angry and accuse the provider of incompetence, ill-will or insensitivity. Oftentimes, people need a little time to reflect on the discussion and talk it over with their loved ones. No one comes lightly to the decision to taper opioids and learn to self-manage pain instead.

The new content page provides assistance with this reflection. The hope is that patients can use the information on the page to further reflect on if and when it may be time to begin learning to self-manage chronic pain. Providers can refer their patients to the page too, ask them to read it, and come back for further discussion.

For countless people over the last four decades, chronic pain rehabilitation has provided hope and a way to take back control of a life with chronic pain. However, it must be approached with sensitivity and compassion. Initially, the idea that one can successfully self-manage chronic pain without the use of opioid medications can be threatening, especially for those who have been managing pain with opioids for some time and for those whose providers have long provided reassurance that it’s okay to take opioids. Nonetheless, if your providers have recently begun to express concerns about the long-term use of opioids or if you yourself have concerns about their long-term use, you might find it helpful to read the new ICP page on the common benefits of learning to self-manage pain without the use of opioid medications.

You can find the new page by clicking on the link here.

References

Gatchel, R. J., & Okifuji, A. (2006). Evidence-based scientific data documenting the treatment and cost-effectiveness of comprehensive pain programs for chronic non-malignant pain. Journal of Pain, 7, 779-793.

Kamper, S. J., Apeldorn, A. T., Chiarotto, A., Smeets, R. J., Ostelo, R. W., Guzman, J., & van Tulder, M. W. (2015). Multidisciplinary biopsychosocial rehabilitation for chronic low back pain: Cochrane systematic review and meta-analysis. BMJ, 350. doi: http://dx.doi.org/10.1136/bmj.h444

Author: Murray J. McAllister, PsyD

Date of last modification: January 23, 2017

About the author: Dr. McAllister is the executive director of the Institute for Chronic Pain (ICP). The ICP is an educational and public policy think tank. Our mission is to lead the field in making pain management more empirically supported. Additionally, the ICP provides scientifically accurate information on chronic pain that is approachable to patients and their families. Dr. McAllister is also the clinical director of pain services for Courage Kenny Rehabilitation Institute (CKRI), part of Allina Health, in Minneapolis, MN. Among other services, CKRI provides chronic pain rehabilitation services on a residential and outpatient basis.

 

How to Get Better When Pain is Chronic

In the last post, we began to introduce a broad definition of coping, as one’s subjective experience, or reaction, to a problem. In this post, let’s expand on this definition and explain how coming to cope better with a problem is a process of coming to experience the problem in a different and better way.

Coping is how we subjectively experience a problem

In our society, when having a problem, we tend to focus on the problem itself, its characteristics and how they do or don’t lend themselves to resolving the problem. In so doing, we put our focus and energy towards fixing or getting rid of the problem. This way of thinking about the problem is all well and good. It likely lends itself to our society’s successes in developing technological solutions to many of the great problems that we have faced.

As an example of this tendency to focus on problems and fixing them, we need only to look to the problem of pain and how we tend to focus on it, and how we try to get rid of it or otherwise reduce it. Knees and hips can now be replaced and we have a large assortment of different medications that can reduce pain and sometimes get rid of it entirely.

However, instead of focusing primarily on the problems itself, we might also coping with painbring our attention to the unique characteristics of each individual with the problem and how they understand it, feel about it, perceive it, and how they behave in regards to it. In effect, we might focus on the characteristics of each person and how these characteristics influence the way individuals experience the problem.

For wherever there is an objective problem in the world, there are also perceiving subjects who have the problem.

We typically call the ways that people experience problems “coping.” It’s something that usually we only direct our attention to when we can’t come up with a solution, or fix, to a problem itself. Nonetheless, it comes in handy in such situations because it offers a way to still get better even if there is no fix to the problem. Namely, we get better at coping with the problem: we can become less distraught by the problem or less impaired by the problem.

In this regard, in returning to our pain example above, we might focus not so much on how to get rid of pain, but how to get better at coping with pain. This change in the approach to getting better may come in handy when pain is truly chronic and you’ve already tried every reasonable procedure and medication without any significant benefit. In such a situation, you focus not so much on how to reduce pain, but on how to increase coping.

In doing so, you can come to learn to tolerate pain that at present is intolerable. You might even get so good at coping that you do more than simply tolerate it – you might get so good at coping that the pain goes from something that is the central focus of your life to something that occurs in the background of your life. It becomes a problem, in other words, that’s not very problematic.

Moreover, you can do such thing without ever reducing pain itself. It can all occur by changing how you experience, or cope with, pain.

It may sound too good to be true.

How coping better makes problems less problematic

It’s important to recognize that people who cope well with a problem tend to experience the problem as less significant or severe than those who don’t cope well with the problem. In other words, when we aren’t coping well, we tend to perceive or judge the problem that we face as more problematic than those who cope well with it. For example, if you had taken a speech class and had actually given many speeches before in the past, you might find the prospect of giving a speech to a packed auditorium as less problematic as someone without your level of expertise and practice. You might find it quite tolerable, in fact possibly even not problematic at all – something in the category of “Well, it was no big deal.” However, another individual, who faces the challenge of giving the exact same speech to the exact same auditorium, might find it overwhelming, paralyzing or intolerable. This individual might judge the problem as one of the hardest things he has ever done in his life.

Objectively, it’s the exact same problem, but the two people subjectively experience it in very different ways. We might say, in such cases, that the differences lie in how well the individuals cope with the problem of giving a speech to a packed auditorium.

How well we cope depends, of course, on how significant the problem is. Big or complicated problems are more difficult to deal with than small or simple problems. Most people will find talking to a group of two or thee people easier than an auditorium of two or three hundred. Nonetheless, how well we cope with problems is also dependent on other things too.

Cope with PainNotably, it’s dependent on certain characteristics of the person who is coping with the problem. If one knows a lot about the problem and is actually an expert on the topic, then typically that person copes better than someone who doesn’t know as much about the problem. Or, if someone has experienced the problem before or expects the problem to occur, then that person often copes better than the individual who has never encountered the problem before or someone who is taken by surprise by the problem. Confidence plays a role here too. Someone who knows a lot about the problem and is well-versed or well-practiced with dealing with the problem tends to be more confident and that confidence aids in coping better. Someone who lacks such confidence tends to be more alarmed or even distraught, which makes for more difficulty in coping. In any of these cases, the subjective experiences of the problem are different for the different people, even if the problem was objectively the same problem.

We could go on indefinitely about the subjective characteristics of the coper, which play a role in how well the individual deals with a problem. We might make a list of subjective characteristics that determine, in part, how well one copes:

  • Degree of knowledge or expertise about the problem
  • How one conceptualizes the problem
  • Degree of accurate information that one has about the problem
  • How much one has practiced overcoming the problem
  • Other attitudes about the problem
  • Degree of confidence in facing the challenge
  • Degree of attention directed on the problem
  • How one feels about the problem
  • What one’s mood is at the time of encountering the problem (e.g., whether one is calm or irritable, depressed or anxious)
  • How much sleep one has had in the past few days prior to encountering the problem
  • How many other problems one is experiencing at the time of encountering a new problem
  • What one goes on to do about the problem (behaviorally)
  • Degree of loving support one has in facing the problem

There are literally countless aspects of the coper that determines, in part, how well one experiences, or copes with, a problem. Some of these characteristics lend themselves to better coping and some lend themselves to worse coping.

Getting better by getting better at coping

So, think about this simple fact: if you have a problem that can’t be entirely fixed, you could still get better by setting out in a concerted effort to get better at coping with it. You could, in effect, obtain training at having the problem and get so good at it that having the problem becomes less and less problematic. It could become, for example, something that occurs in the background of your day-to-day activities, but for the most part you’ve moved on and focus on the meaningful activities of your life. Indeed, there is simply no end to how good one can get in coping with a problem, even a problem that can’t be entirely fixed, like chronic pain.

Here is where true hope lies. Even when your pain is chronic, you can get so Needing Hopegood at coping with it that living with chronic pain is no longer a distressing or impairing problem. Alternatively, you can get so good at coping with it that it no longer requires opioids to manage it and so you can move on with the rest of your life.

Usually, this level of advanced coping requires a concerted effort of training, done over time, and typically with a team of healthcare providers who coach you and support you throughout the process. Traditionally, patients find such support and training in chronic pain rehabilitation clinics. Such clinics are a type of pain clinic that involve an interdisciplinary team of healthcare providers (consisting of at least pain psychologists, medical providers, and physical therapists, but oftentimes other kinds of providers as well) who work with patients over an extended period of time in the pursuit of not so much reducing pain, but improving the patient’s coping. Such clinics are not new, but have been around since at least the early 1970’s and as a result they have about four decades of published research proving their effectiveness (see, for example, these meta-analytic studies and literature reviews: Chou, et al., 2007; Flor, Frydrich, & Turk,1992; Gatchel & Okifuji, 2006; Neusch, et al., 2013; Turk, 2002).

When talk of the possibility of coping better feels like a criticism

Sometimes, when healthcare providers like me talk in these ways, it feels to patients with chronic pain like a judgment. It feels like blame. It feels like you’re being told there’s something wrong with you — that you aren’t coping well enough.

Oftentimes, when patients have people in their lives who judge them or stigmatize them for how they have been coping, they can come to hear their healthcare provider talking about the benefits of learning to cope better as a similar criticism.

In such cases, patients can come to refuse the recommendation to participate in chronic pain rehabilitation. The hopeful message that there is a traditional and scientifically proven treatment that helps patients to learn to cope better with pain can be met with quick and sometimes sharp rebuttals. Common examples are the following:

  • The provider must be insensitive.
  • The provider must not know what he or she is talking about (i.e. the provider is incompetent).
  • The provider doesn’t (or won’t) recognize that I’m coping as well as humanly possible given the amount of pain I have.
  • The provider must not have chronic pain or otherwise he or she would understand.
  • The provider must not believe me that I have real pain.
  • The provider is just out to make money and so wants me to go to yet another treatment from which he or she will profit.
  • The provider just wants me to get off opioid medications.

Obviously, talk of how to learn to cope better is a sensitive topic. It’s as if the same words can engender almost two opposite interpretations. The healthcare provider intends it to be a hopeful message – you can get better by undergoing extensive training over time and as a result come to cope better with a condition that is incurable. The patient, however, can hear it as an insensitive criticism of how the patient isn’t coping well right now.

Importance of trusting your healthcare provider

In such situations, what can make the difference is having a good, therapeutic relationship with your healthcare provider. If you know your provider and trust him or her, then you know that your provider isn’t just being mean or insensitive or ignorant of what’s it like to have pain or out to make money off you. Instead, you know that your provider has your best interest at heart.

Your thoughts

Have you ever had a healthcare provider talk to you about chronic pain rehabilitation or learning how to cope better with pain? What were your reactions? Have you ever attended a chronic pain rehabilitation program? Why or why not?

[Please note our comment publishing policies. All participants in the discussion will appreciate your cooperation with this policy.]

References

Chou, R., Amir, Q., Snow, V., Casey, D., Cross, T., Shekelle, P., & Owens, D. K. (2007). Diagnosis and treatment of low back pain: A joint clinical practice guideline from the American College of Physicians and the American Pain Society. Annals of Internal Medicine, 147(7), 478-491.

Flor, H. & Frydrich, T., Turk, D. C. (1992). Efficacy of multidisciplinary pain treatment centers: A meta-analytic review. Pain, 49, 221-230.

Gatchel, R., J., & Okifuji, A. (2006). Evidence-based scientific data documenting the treatment and cost-effectiveness of comprehensive pain programs for chronic non-malignant pain. Journal of Pain, 7, 779-793.

Neusch, E., Hauser, W., Bernardy, K., Barth, J. & Juni, P. (2013). Comparative efficacy of pharmacological and non-pharmacological interventions in fibromyalgia syndrome: Network meta-analysis. Annals of the Rheumatic Diseases, 72, 955-962

Turk, D. C. (2002). Clinical effectiveness and cost-effectiveness of treatments for patients with chronic pain. The Clinical Journal of Pain, 18, 355-365.

Author: Murray J. McAllister, PsyD

Date of last modification: September 11, 2016

About the author: Dr. McAllister is the executive director and founder of the Institute for Chronic Pain (ICP). The ICP is an educational and public policy think tank. Our mission is to lead the field in making pain management more empirically supported. Additionally, the ICP provides scientifically accurate information on chronic pain that is approachable to patients and their families. Dr. McAllister is also the clinical director of pain services for Courage Kenny Rehabilitation Institute (CKRI), part of Allina Health, in Minneapolis, MN. Among other services, CKRI provides chronic pain rehabilitation services on a residential and outpatient basis.

Can you experience the same pain differently?

A major tenet of chronic pain rehabilitation is that the way you experience pain is not the only possible way to experience pain. In other words, the experience of pain differs across individuals and can even differ in the same individual across time. As such, it’s possible to have a different experience of pain than the experience that you have today, even if your pain remains on a chronic course.

This point isn’t necessarily controversial. Patients commonly make a similar point themselves. For instance, patients sometimes express that pain is a subjective experience that only they can feel.

The rub, though, lies in the consequences we draw from such a point. We can draw different consequences.

Patients often make the point about the subjective nature of pain as a means to defend against stigma. It’s a way to say that others shouldn’t judge if their experience of pain differs from the patient’s experience of pain. While it’s a good point that no one should ever stigmatize patients for how they experience pain, we might draw an altogether different inference from the point that pain is a subjective experience. This inference has nothing to do with the issue of stigma and it is often drawn by healthcare providers, particularly pain psychologists and others who work in chronic pain rehabilitation. This additional inference is that you can come to experience pain differently.

In other words, the subjective nature of pain is such that different people can have different experiences of pain and what this shows is that it is possible to experience pain differently than how you experience it today. You can learn, in other words, how to have pain in other ways. It’s a hopeful message. It’s the foundation for what pain psychologists do everyday – help people come to experience their pain differently, in ways that are better than how they presently experience it.

Coping with pain as changing how you experience pain

In effect, what’s happening is that, with the help of pain psychology and chronic pain rehabilitation, people come to cope better with pain. They literally experience their pain in new and different ways. They experience pain in ways that are better than they had experienced it previously.

They know, for instance, that their pain isn’t a sign of a fragile injury, which is experience painabout to get worse at any point in time. Subsequently, they are not alarmed by pain and do not understand it as some thing for which they must stay home and rest. Instead, they tend to see pain as akin to white noise, something that is there, but remains in the background of their attention. They remain grounded and focused on their activities, which they continue to do. They go to work and go to their children’s activities and go to the neighborhood potlucks. They do all these things with pain.

Now, that’s what coping really well with pain looks like.

When people cope well with pain, they literally experience it differently than someone who isn’t coping well – the individual, for instance, who is alarmed by pain, sees it as a function of a deteriorating disease that is inevitably going to get worse, and so subsequently believes the best course of action is to avoid the activities of daily life and instead stay home and rest, out of concern for not making their condition worse.

What would it be like to cope so well with pain that you literally experience it in the manner I previously described above – as something that remains present, but something that nonetheless doesn’t deserve a lot of day-to-day attention and emotional energy and so remains in the background of your daily activities like white noise?

There are countless lessons to learn that can be helpful when learning how to do it. The pain psychologists of a chronic pain rehabilitation clinic or program can help you to learn them. We have discussed a number of them in the posts of this blog (see, for example, posts on catastrophizing, all-or-nothing thinking, mind-reading, perfectionism, among others).

In our next post, we’ll review yet another important cognitive distortion that adversely affects how people experience pain. It occurs when people understand pain as something that always signals harm. It can happen, for instance, when people with back or neck pain understand their pain as solely the result of a fragile, degenerative condition of the spine. In large measure, this cognitive distortion is a consequence of how certain parts of the healthcare system understand back and neck pain as the symptom of degenerative disc disease. It’s therefore a complicated issue as it plays out in both patients and some healthcare providers.

It’s also, though, an important issue. Every rehabilitation provider tends to encourage patients to exercise, move and get back into life, within some reasonable limits. However, people don’t tend to do these things when they see their pain as signaling harm. Instead, what people tend to do when understanding their pain as indicative of a fragile injury is to become mildly alarmed, stay home and rest.

It’s therefore important to learn when pain is a sign of injury (for which you should become alarmed, stop what you are doing and seek care) and when pain is not a sign of injury (for which you try to stay grounded, redirect your attention elsewhere and remain engaged in the activities of your life). In other words, sometimes pain has a psychobiological function of signaling injury or illness and sometimes pain continues even though it has lost this function. It’s important to know the difference. In the former case, you take heed. In the latter case, you try to tune it out as white noise.

Will discuss more in the next post!

Date of last modification: 8-29-2016

Author: Murray J. McAllister, PsyD

About the author: Dr. McAllister is the executive director and founder of the Institute for Chronic Pain (ICP). The ICP is an educational and public policy think tank. Our mission is to lead the field in making pain management more empirically supported. Additionally, the ICP provides scientifically accurate information on chronic pain that is approachable to patients and their families. Dr. McAllister is also the clinical director of pain services for Courage Kenny Rehabilitation Institute (CKRI), part of Allina Health, in Minneapolis, MN. Among other services, CKRI provides chronic pain rehabilitation services on a residential and outpatient basis.

Developing an Observational Self: How to Cope with Pain Series

From the time before Socrates in ancient Greece there stood a temple built upon a spring at a location the Greeks would have considered the center of the world. Inscribed on the walls of this holy temple was the simple phrase, “Know Thyself”.

This simple phrase inspired Socrates to a life of learning and teaching, and, from him, Plato learned to be a philosopher and later came to teach Aristotle. Subsequently, Western civilization, in large measure, began.

This maxim – “Know thyself” — and others similar to it were not uncommon in the ancient world. Indeed, a few thousand years previously, early Hindus and later Buddhists practiced a form of moment-to-moment self-knowledge, later coming to be called mindfulness.

The directive inherent to this maxim has two components. The first is to pay attention. In observational selfother words, slow down and observe what’s happening. In today’s language, we might express the maxim as something like, “Get out of your head and notice what’s going on around you.” When we carry out such a dictum, we become observant and reflective. We see or otherwise perceive things that we might not have heretofore noticed. We subsequently create opportunity to consider what it is we observe.

Good things happen when we do. We see good things and become appreciative. We stop and smell the roses because we were observant enough to even notice them as we walked by and as a result we are able to appreciate their visual and olfactory beauty. Whereas in one moment our kid might be bugging us because of her need for attention is interrupting our apparent need to make a phone call or put dinner on the table, in the next moment, once we get out of our head, we recognize just how funny or cute the kid is and we subsequently are overwhelmed by how much love we have for her.

So much of life goes unnoticed because we are simply and persistently reacting to whatever thoughts, feelings and needs that pop into our attention. Whatever pops into our heads tends to have a sense of immediacy to which we react impulsively, without thinking in the sense of thoughtful consideration. It’s just a never-ending chain reaction of stimulus and response, like billiard balls knocking into each other. Notice that when we live life as if we are a player in a video game that goes on in our head, simply and persistently reacting to whatever momentary thought, feeling, or need that pops into our head, so much of what goes on around us gets missed.

We don’t see how cute our kid is in that moment. We don’t notice that our spouse made coffee for us before leaving for work. We don’t smell the fresh air. We don’t taste our lunch. We don’t fully appreciate how funny it was when our coworker or neighbor made that comment yesterday.

Instead, we were busying ourselves with the immediacy of whatever popped into our head at the time.

Notice too all the things we could have done in those moments but didn’t do simply because it never occurred to us. When we react to whatever thought, feeling or need that pops into awareness at any given time, it’s as if the reaction that we have is the only possible thing to do at the time. We might even justify the reaction, if anyone ever were to ask us about what we did, by saying ‘Oh, I had to,’ as if the thing we did was the only possible thing that could have been done. However, it’s not really true, and this point brings us to the second good thing that happens when we get out of our heads and start to observe what in actuality is happening in any given moment.

Namely, we become liberated from being a passive recipient of what happens to us to an active decision-maker of a well-informed life. By observing what in actuality is happening in life, and by considering the various possible ways we might respond, we exercise choice. No longer is our life dominated by the apparent ‘must’ and ‘have to’ and ‘got to’, but rather we are free to choose. When we pay attention, we recognize that we do not have to simply endure things happening to us. We are not victims. We have the power to choose among a number of different options as long as we slow down enough to recognize and consider the options that are available to us.

The simple maxim – Know thyself”, then, is a truth that sets us free. It’s freedom from a determinism of automatic reactions to whatever life gives us. We no longer ‘have to’ do this, that, or the other thing, but are free to choose how we live our life. We no longer ‘can’t’ do anything but the reaction that we have automatically done countless times in the past and are now free to choose how we might respond and move forward. From moment to moment, we are free to choose how to respond even to the things in life that we do not choose – like bad things that happen to us. We still are free to choose how we react to them and the perspective by which we see them.

In sum, the second good thing that happens when we observe what’s happening is that we become intentional about what we do, how we react to things, and even how we perceive the things around us.

This ability to observe life and intentionally choose how to respond to the things that come up from moment to moment is the main goal of psychotherapy. Freud called this ability the development of an ‘observing ego’ and considered analysis a way to develop this ability. In more recent psychotherapies, we call it an ‘observational self’. It’s the ability, as described, to step out of any given moment, consider what’s happening, and intentionally choose how to react. Of course, in this day and age, we also call it ‘mindfulness’.

What does developing an observational self have to do with pain?

The development of the ability to step out of the moment and reflect on how to react to pain is the initial and most important thing to do in pain management. Everything else in pain management follows from this skill.

Pain has a sense of immediacy about it. It’s a sensation that is inherently emotionally alarming and to which we automatically react with avoidance behaviors – we stop what we’re doing, pull away and guard. This sensory, emotional and behavioral experience happens all at once, of course, and it happens automatically. We don’t typically choose any of it. The sensation just is alarming and we pull away and guard without ever intending to do so.

For example, if you were out hiking in the woods and, without looking, you stepped in a hole and twisted your ankle, you’d have pain. That is to say, you would have a sensation that was emotionally alarming and to which you would stop walking and guard your ankle in some manner. The whole experience would be almost instantaneous. It would also be automatic, in a sense. The alarming sensation and behavioral avoidance would occur without any intentional decision-making on your part.

However, if you had chronic pain, and you set out to pay attention to the pain that occurred with activities, you could learn to make the whole experience more intentional. You would do so in a multiple step process. You would first simply pay attention to the pain that occurs and not be taken by surprise by it. Chronic pain often has a degree of predictability that the pain of an acute injury doesn’t have. So, by paying attention, you could practice the skill of not being taken aback by the pain. Just as importantly, you could recall that you have chronic pain and that you’ve had it for some time and you know what it is. In most cases, chronic pain is the result of the nervous system having become highly reactive to the stimuli of activities that are normally not painful to do – like walking, sitting, standing up, laying. You could consider that, even though it is painful, these activities are safe to do– that you are not injuring yourself even though it is painful. In this manner, you start to control the sense of emotional alarm that you have with pain. You set out to intentionally remain emotionally grounded in the presence of pain. To this end, you also practice taking deep, diaphragmatic breaths to assist you in remaining calm. From this new-found perspective, you can also choose how to behaviorally react. You intentionally choose to engage in the activity and have the sensation while practicing remaining calm.

Suppose, for example, every time an individual with pain sits down she knows she’ll experience pain. More often than not, however, she doesn’t keep this fact in mind and she goes about her day, like most of us, simply reacting to whatever pops into her attention. She does this and then that, checking things off her to do list. Each time she sits down, she lets out a soft groan, grabs whatever is within reach in order to brace herself, and becomes, for an instant or two, emotionally and physically tense. The pain is severe and it takes her breath away.

She could, though, with some proper coaching from a psychologist at her pain clinic, set out to learn and practice the ability to step out of the moment and pay more attention to her actions. She could then practice slowing down the process of experiencing pain. In doing so, she pays attention to what she does and predicts the severe pain prior to sitting down. In this way, she isn’t taken by surprise each time. With knowing that it’ll hurt, she takes some deep diaphragmatic breaths as she works and reminds herself that even though it is painful she isn’t injuring herself every time she sits down. She intentionally recognizes that it is safe to sit down even though it hurts badly. In these ways, she practices remaining grounded while having pain. With her budding abilities to remain calm in the presence of pain, she intentionally sets out to control her pain avoidance behaviors. She makes the decision to stop letting out the groan because she’s predicted the pain and isn’t taken aback by it as she sits down. She intentionally stops her tendency to abruptly reach out for something to hold on to while she sits, reassuring herself that it is safe to sit down. She also tries to refrain from grabbing her back and instead sets out to remain as calm as she can be in the presence of her pain, even severe pain. She intentionally does all things, moreover, on a repetitive basis through the course of her day, day after day. She discusses her strategies with her psychologist each week, and her psychologist gives her pointers, which she tries at home. Over time and with practice, she gets better and better at it. By developing her abilities to pay attention, observe herself and engage in intentional decision-making, she comes to be able to control, in part, her experience of pain. She comes, in other words, to be able to control the alarming and behavioral aspects of pain and subsequently becomes able to remain grounded and productive in the course of her day, even though she continues to have severe pain.

This description is what good coping looks like. Good coping is not getting rid of pain, but getting so good at reacting to pain that it is no longer as problematic as it once was. It requires the development of an observational self from which you can have pain, remain aware of how you are reacting to it, and intentionally attempting to remain grounded and active while having pain.

From the river Ganges to the temple at Delphi and all the way through to the modern pain clinic, the dictum to know thyself travels through time because good things happen when we follow it. The ability to pay attention and engage in intentional decision-making when having pain is the initial and most important skill to develop in pain management.

Author: Murray J. McAllister, PsyD

Date of last modification: 6-19-2016

Does Your Pain Clinic Teach Coping?

As we’ve discussed in an earlier post, not all pain clinics are alike. To be sure, all pain clinics provide therapies aimed at reducing pain. Some, however, don’t stop there. They set out to systematically coach patients to cope better with pain that remains chronic.

Types of Pain Clinics

Despite the fact that they all operate under the name ‘pain clinic’, there are at least four different types of clinics.

Interventional pain clinics:  Interventional pain clinics tend to focus on minimally invasive procedures, or ‘interventions’, coping with painwhich aim to reduce pain. To be fair, most interventional pain providers would assert that they also aim to improve functioning, which means increasing a patient’s ability to engage in the activities of life, such as being able to engage in household chores or returning to work. However, interventional pain clinics primarily aim to increase functioning by attempting to reduce pain, under the assumption that people will be able to do more when their pain is reduced (i.e., in an inverse relationship that as pain reduces functioning increases).

Examples of minimally invasive procedures that one might obtain at an interventional pain clinic are epidural steroid injections, nerve blocks, radiofrequency neuroablations, spinal cord stimulator implants and intrathecal drug delivery device implants.

Notice that nowhere within this list is there specific time and resources set aside to teach patients how to cope better with pain that remains despite the use of the afore-mentioned procedures. While certainly individual clinics and/or providers might vary, most interventional pain clinics concentrate on providing procedures, not providing groups or classes or even one-to-one time to coach people on how to live well with pain that remains refractory to procedures.

The observation is not a complaint. It’s just not what they do, just as bankers typically don’t provide legal advice, even though in some areas of the respective fields there is some overlap.

Long-term opioid management clinics:  Long-term opioid management clinics tend to provide access to the long-term use of narcotic pain medications. The aim of this type of clinic is to reduce pain and secondarily increase functioning. Akin to the interventional pain management aims, the assumption is that when pain is reduced, patients with pain will be able to do more and thereby their functioning increases.

Long-term opioid management clinics typically provide access to opioid, or narcotic, medications on an indefinite basis. Usually, patients see the healthcare providers on some regular interval to obtain a prescription of medications that lasts only until their next appointment. Oftentimes, this interval of time is monthly, though sometimes it’s shorter or longer in duration. Typically, the two main reasons such care comes to an end is when patients abuse the medications, in which case the patient is potentially referred to a substance dependence treatment program, or when patients become too tolerant to the medications and the medications are therefore no longer effective, in which case the patients are referred to another type of pain clinic.

Often, in long-term opioid management clinics, there might be a little bit more emphasis on coping with pain than in interventional pain clinics. So, providers might encourage exercise, staying active, the use of diaphragmatic breathing, or the use of more traditionally passive coping strategies, such as ice, heat, home traction units, or TENS units.

However, the primary focus of long-term opioid management clinics typically remains on providing access to opioid medications. Of course, there might be some exceptions, but for the most part the care in such clinics aim to reduce pain through the use of opioids and the elementary basics of coping that they teach are intended to complement opioids, not substitute for their use.

Orthopedic and surgery clinics:  Orthopedic and surgery clinics provide invasive procedures aimed to reduce pain. Surgery clinics make the same assumption about functioning as the previous two clinics do — that the primary purpose of the procedures is pain reduction and secondarily to increase function. How this assumption typically plays out in surgery clinics is that patients commonly remain off work prior to and immediately after obtaining a surgical procedure and, once a procedure reduces pain, patients go back to work.

Examples of procedures that surgery clinics perform are arthroscopic surgeries of various joints, joint replacement surgeries, and spine surgeries, such as laminectomies, discectomies, and fusions.

Chronic pain rehabilitation clinics:  Chronic pain rehabilitation clinics provide interdisciplinary rehabilitation care that aim to reduce pain, but primarily increase function. In this way, chronic pain rehabilitation clinics are different. Chronic pain rehabilitation clinics point to clinical and scientific evidence that pain is one of many factors that determine a patient’s functioning – one’s ability to remain engaged in the activities of life, such as work. What clinical experience and science tells us, in other words, is that how one responds to adversity, such as pain, is as important as how significant the adversity is – especially in terms of how one goes on to live with the adversity.

The importance of this observation cannot be underestimated. It elevates the importance of increasing coping to the same degree of importance that reducing pain has. So, to take an example, if we want to help people with chronic pain return to work, then we can approach this problem in two different ways: 1) we can focus on reducing pain, under the above-noted assumption that when pain is reduced people can subsequently return to work; or 2) we can teach people with chronic pain to respond more effectively to the pain so that they know how to cope with pain so well that the pain is no longer as problematic, or disabling, as it once was and subsequently they learn how to return to work even with pain.

Chronic pain rehabilitation clinics provide interdisciplinary rehabilitation care, which means it’s care that focuses on what the patient can do to reduce pain and live better despite having pain. Patients learn to engage in various lifestyle changes, which, when done over time, reduce pain. More importantly, because chronic pain is typically chronic and cannot be entirely cured, patients also learn how to change the ways they react to pain so that they can still do things in life, such as return to work and engage in other daily activities of life, even though they continue to have pain. In other words, chronic pain rehabilitation clinics provide systematic education on how to remain functional in life despite having pain.

In this way, chronic pain rehabilitation clinics teach coping in a way that no other pain clinic does. In fact, they tend to emphasize coping over pain reduction because they base their approach on acceptance of the fact that chronic pain is really chronic. There tends to be no misleading anyone, as typically, chronic pain can only be reduced so much in whatever clinic one seeks care. Rather than repetitively trying to cure an incurable, or chronic, condition, chronic pain rehabilitation aims to increase patients’ abilities to cope with pain and help them to get so good at dealing with it that pain is no longer the showstopper that it once was. Patients come to learn, in other words, to accept pain, remain grounded in the presence of pain, and make an intentional choice to go to work and remain at work (or some other similar activity of life) despite having pain. With practice and expert coaching from the staff of the chronic pain rehabilitation clinic, pain becomes no longer the central focus of life, but rather is something that is just a side issue, with work, family and other activities being the most central aspects of life.

Coping with pain

Sometimes, patients with chronic pain won’t believe that such progress is possible. They might be sensitive to the possibility that one could have chronic pain and remain at work, and so tend to assert that it is impossible. They might also fear the sting of stigma if they acknowledge that they might be able to learn a thing or two about how to cope better with pain. Instead, they might assert that they already know how to cope with pain and that they cope better than anyone else could, who might find themselves in a similar situation.

In these ways, some people can have difficulty with openly acknowledging that they don’t cope as well as they’d like or could.

However, the possibility of getting better through learning to cope better doesn’t have to be perceived in this way. Most people would say that there is nothing wrong with you if you don’t know how to read very well, or don’t know how to change a tire on your car, or don’t know how to speak a foreign language, or don’t know how to play basketball very well. It’s okay to not know how to do certain things really well.

In fact, most people think learning new things is good. It’s admirable to learn something really well. In learning, the person who learns has to acknowledge and be okay with the fact that they don’t know everything already. In most situations of learning, no one ever has a problem with this aspect of learning.

If you are okay with learning how to cope with pain really well, then chronic pain rehabilitation clinics might well be very helpful to you. Everyday, people with moderate to severe chronic pain learn how to cope so well with pain that they become much more functional in life. They go back to work. They attend family functions again. They do household chores and do fun things again with friends and family. In other words, they get back into life. Of course, in order to learn how, you’d have to be okay with being in a student role. But, again, most of the time, we think that learning is a good and admirable thing to do. The same can be true of learning how to cope better with pain.

Author: Murray J. McAllister, PsyD

Date of last modification: 3-23-2016

Chronic Pain Rehabilitation

A central tenet of chronic pain rehabilitation is that what initially caused your pain is often not now the only thing that is maintaining your pain on a chronic course. Let’s unpack this important statement.

It’s no accident that healthcare providers commonly refer to chronic pain syndromes as ‘complex chronic pain’ or ‘complicated chronic pain.’ It’s because pain, of course, typically starts with an acute injury or illness, but it isn’t typically maintained on a chronic course by the initial injury or illness. For after all, injuries and illnesses tend to heal. Rather, something else takes over to maintain pain long past the healing of the initial injury or illness that started it all. In most cases, this transition from pain of an acute injury or illness to chronic pain involves the development of central sensitization.

Central SensitizationCentral sensitization is a condition of the nervous system in which the nervous system becomes stuck in a heightened state of reactivity so that the threshold for stimuli to cause pain becomes lowered. As a result, light amounts of stimuli to the nerves, which typically aren’t painful, become painful. In normal circumstances, it takes a high level of stimuli – like a slug in the arm – to cause pain, but in chronic pain states any little thing might be enough to cause pain. Simple movements hurt, even such movements as sitting down or getting up from a chair or walking. The amount of stimuli to, say, the low back that is associated with these movements shouldn’t be painful, but they are because the nerves in the low back have become increasingly sensitive — so sensitive, in fact, that any amount of stimuli to them is enough to cause pain.

This condition of central sensitization explains why not only simple movements can hurt, but also why light amounts of tactile pressure can hurt. Patients with chronic pain often have had a healthcare provider ask them, “Does this hurt?” when lightly touching or pressing the painful area of their body during an examination. This light amount of pressure is often enough to send the patient through the roof. In other circumstances, you might notice that a hug or massage, which typically should feel good, is enough to cause pain. It’s all because the nerves in the painful area of the body have become so reactive that any little thing sets them off.

Other forms of stimuli, beyond that which is associated with movement and touch, can also become painful once the transition from acute pain to chronic pain occurs. As most anyone with chronic pain knows, stress can cause pain too. The stress of a bad night’s sleep or the stress of work or family problems shouldn’t typically cause pain, but it does once the nerves become stuck in the highly reactive state of central sensitization. It may also be why changes in weather can cause pain. Emotional stress or changes in temperature or barometric pressure shouldn’t typically be enough stimuli to cause pain but they do once pain occurs as a result of central sensitization.

Sensitive nerves are normal in acute injuries or illnesses

The sensitivity of the nervous system is normal in acute pain. Say, for example, you step on a nail. We often think that the resulting tissue damage from the injury (in this case the puncture wound from the nail) is the only thing that matters when it comes to pain. However, even in cases where there is demonstrable tissue damage, we also need a nervous system to have pain. Without nerves and a brain, we would never be able to feel the tissue damage associated with an injury.

In our example, the nerves in the foot detect the tissue damage and send messages along a highway of nerves from the foot, up the leg and to the spinal cord. From the spinal cord, the messages travel up to the brain, where the messages are processed by different parts of the brain. The result of this processing is the production of pain. In other words, the brain produces pain in the foot. The brain and spinal cord (i.e., the central nervous system) produces pain in response from messages sent from nerves in the foot (i.e., the peripheral nervous system).

In this process, the brain and the rest of the nervous system team up with the endocrine (hormonal) system and the immune system. With the help of hormones and neurotransmitters, the brain tells the immune system to flood the area around the injury with inflammation. Inflammation is white blood cells and certain chemicals that assist in fighting infection and repair of the tissue damage. While engaged in these activities, inflammation also makes the nerves in the area around the injury super sensitive, which, again, is why the area of the body around an injury becomes so painful to touch or pressure. In most cases, the injury heals and the brain tells the immune system that inflammation is no longer needed and so the inflammation subsides. As a result, the pain of the injury also subsides upon healing because without the inflammation the nerves return to their normal level of sensitivity. So, they stop sending messages to the brain when normal levels of stimuli to the foot occur, such as when walking on the foot.

However, sometimes, the nervous system remains stuck in a vicious cycle once the tissue damage associated with the acute injury heals. The brain, in a sense, continues to call for inflammation even after the tissue damage is repaired. With the continued presence of inflammation, the nerves in the area of the initial injury remain sensitive so that any stimuli to them, even if they wouldn’t typically be painful, continue to produce pain. The continued pain thereby keeps the brain calling for more inflammation, thus eliciting continued sensitivity of the nerves to normal stimuli and subsequently more pain.

When this process continues past the point of healing of the initial injury, it’s called central sensitization, as we’ve discussed.

Complex or complicated chronic pain

Once central sensitization occurs, any number of things can reinforce it. Just think of all the stressful problems that occur or can occur as a result of having chronic pain. Loss of work and subsequent disability can cause loss of income and significant financial hardship. The loss of work is often a blow to one’s sense of self-worth and self esteem. Chronic boredom or social isolation can also set in. Pain often produces insomnia, which further wears on the nerves. Because pain is also emotionally alarming, people with chronic pain also commonly become fear-avoidant of different activities that are associated with pain. Such distress lends itself to becoming persistently focused on pain so that life becomes predominated by pain and its associated difficulties. Anxiety and depression can secondarily occur.

All of these problems are stressful. The stress associated with these problems affects the nervous system. It makes an already reactive nervous system more reactive. The threshold that the nervous system has for producing pain becomes lower and lower. As a result, the pain of chronic pain tends to become worse and more widespread.

Notice, though, that the initial injury or illness associated with the onset of pain isn’t getting worse. It may not even be a factor at all anymore, for as we’ve discussed, most injuries and illnesses heal (e.g., lumbar strains). Sometimes, of course, the initial condition associated with onset of pain continues (e.g., rheumatoid arthritis). However, in either case, the nervous system is now also playing a role in the cause of pain. The nervous system is now maintaining pain on a chronic course. Any number of stressful problems that occur as a result of the pain can then play a further exacerbating role in the long-term maintenance of chronic pain.

So, a central tenet of chronic pain rehabilitation is that, in most typical situations, what initially caused your pain is not now the only thing that is maintaining your pain on a chronic course.

What to do about chronic pain?

The public and even some healthcare providers commonly don’t take into account the role that the nervous system plays in maintaining chronic pain. Instead, the focus of care tends to remain on looking for evidence of any lingering tissue damage or disease associated with the initial injury or illness, respectively. The presumption is that pain must be caused by either tissue damage or disease and so the initial condition that started the pain must remain unhealed. The possibility never gets considered that the nervous system has changed so that the threshold for stimuli to cause pain has lowered.

This type of thinking leads to a lot of repetitive interventional and surgical procedures. In a pain clinic, it is not uncommon to see patients who have had numerous epidural steroid injections, neuroablation procedures or spine surgeries, repeated at the same site of the initial injury. The presumption is that the tissue damage associated with the initial injury remains unhealed and so is therefore the “pain generator”. However, repetitive attempts to rectify the tissue damage associated with the initial injury often remain ineffective because the pain is no longer due (or predominantly due) to tissue damage associated with the initial injury. Rather, the pain has transitioned from acute pain to chronic pain and as such it is due to the nervous system having lowered its threshold for producing pain. Simple movements and light touch hurt – not because the tissue damage is so great – but because the central nervous system maintains the peripheral nerves in a highly sensitive state.

From here we can see why the afore-mentioned central tenet is so important to chronic pain rehabilitation. In contrast to the typical interventional and surgical forms of pain management, chronic pain rehabilitation focuses its interdisciplinary therapies on the nervous system. Chronic pain rehabilitation aims to down-regulate the nervous system so that the nervous system is not so reactive and more approximates a normal threshold for producing pain. In other words, the goal is to get to a state of the nervous system in which it again requires the force of a slug in the arm to cause pain, and not just a simple movement like walking or sitting or a light touch.

Chronic pain rehabilitation is an empirically effective form of pain management – meaning, numerous scientific studies over the last four decades have shown that interdisciplinary chronic pain rehabilitation helps people to reduce pain, get off narcotic pain medications, and return to work in some capacity.

The key components of interdisciplinary chronic pain rehabilitation are the following:

  • Cognitive-behavioral based pain coping skills training
  • Mild aerobic exercise
  • Use of antidepressants and anti-epileptics for pain
  • Relaxation therapies
  • Exposure-based milieu therapies

All of these therapies are pursued in a coordinated fashion on a daily basis over a number of weeks. Patients learn them and become adept at independently pursuing them. As a result, patients continue to engage in them on an independent basis over the lifetime.

The target of all these therapies is the nervous system, particularly the central nervous system (i.e., the brain and spinal cord). They improve the health of the nervous system and in doing so they reduce the sensitivity of the overall nervous system and thereby reduce pain. In other words, interdisciplinary chronic pain rehabilitation focuses care on what’s now maintaining your pain and not on what initially started it way back when.

Author: Murray J. McAllister, PsyD

Date of last modification: 2-14-2016

Coping: Ideas that Change Pain

Coping-based healthcare is often misunderstood in society and, as a result, it is commonly neglected by healthcare providers and patients alike. Examples of such care are chronic pain rehabilitation for pain disorders, cardiac rehabilitation for heart disease, psychotherapy for mental health disorders, or diabetic education for diabetes. These therapies are often the last thing that healthcare providers recommend or the last thing people are willing to try, even though they are typically some of the most effective treatments for their respective conditions.

CopingThis misunderstanding and neglect is likely due to a number of reasons. Our healthcare system is set up for providers to focus on making patients well, not teaching them how to become well or get better at dealing with a health problem that won’t go away, such as chronic health conditions.

Another reason may be our shared desire for a quick fix. Understandably, when faced with a health problem, we often initially want something that will take it away, rather than coming to terms with the need to change our lifestyle in order to get healthier or become more effective at coping with the problem that we face.

Yet another reason is our societal misunderstanding of the role that genetics play in most of these chronic conditions. It’s not uncommon for people to report that their depression or back pain or heart disease or type II diabetes runs in their family, as if to say, there really isn’t much they can do about it. To be sure, at least some of these conditions, if not all of them, run in families, but a genetic predisposition is not destiny or fate. In all these conditions, the lifestyle choices we make in our lives also play a role and it’s healthy changes in how we live our lives that can make all the difference.

There’s also something about going to see a healthcare provider to learn how to be healthier that just doesn’t seem as real or effective as going to see a healthcare provider for a medication  or a high-tech test or an injection or a surgery. Coping-based care, in other words, seems so intangible. Acute medical care is something that you can touch, see, hear, even smell at times. You walk away with medications in your hand, a dull ache at the site of where you got the injection, or a hospital wristband. Such tangibles are missing when you see your rehabilitation provider or your psychotherapist or your diabetic educator. You walk away with nothing but ideas on how to make healthy changes in your life. In other words, what you walk away with is all in your head.

Speaking of which, yet another reason why coping-based therapies get short shrift in our healthcare system is stigma. We all might intellectually acknowledge that we could make healthier choices in our lives or deal better with the chronic conditions that we have, but hardly anyone ever wants to openly acknowledge it to others for fear of being blamed. In the face-to-face encounter of the examining room, healthcare providers too typically have a hard time bringing up the fact that, say, a particular patient could benefit from learning how to cope better with his or her problems. The act of bringing it up implies a judgment that the patient isn’t coping well and it’s a sensitive topic. People can become upset. Healthcare providers, despite all their training, are just people too and they become nervous in such situations, often too nervous, and so the whole topic never gets raised. It’s easier to focus on the tangibles – the medications, tests, injections, and surgeries. Even if the need for learning better coping strategies does get brought up, it’s not uncommon for patients to refuse it, asserting instead that they actually cope really well, despite evidence to the contrary. It can seem advantageous to deny that you are coping poorly when, in our society, coping poorly is a judgeable offense.

For any or all these reasons, coping-based therapies are commonly considered an after-thought, after the ‘real’ healthcare has been tried and failed. It’s too bad because these therapies can be highly effective.

In an ideal (i.e., stigma-free) world, these therapies would be able to stand on their own and be recognizable as the effective therapies that they are. However, we don’t live in such a world.

All of us need to do our part to promote these therapies so that people who need them gain the liberty to use them and become healthier and happier. That’s what’s really at stake here: because of stigma and ignorance and fear, we as a society don’t readily feel free to utilize treatments that can make us healthier and ultimately happier people, even when we experience health problems that can’t entirely be cured.

To this end, at the Institute for Chronic Pain, we make every effort to promote the legitimacy and effectiveness of coping-based rehabilitation treatments for pain. Using common, everyday language, we develop explanations of them that show how and why they can be helpful. We persistently discuss issues related to stigma, particularly how to respond to it so that people can overcome the sensitivity that comes along with openly acknowledging the need to learn how to cope better with the pain that remains chronic on a life-long basis. We then use social media as a means to proliferate these ideas and make them known on an international scale. In short, we promote ideas that change pain.

Our latest effort in this regard is a new content page on our home website. It’s on the nature of coping and how learning to cope better with pain is one of the most powerful interventions we have in the field of chronic pain management.

We hope that you find it helpful. If you do, please pass it on within your social network. Take the risk to acknowledge that there’s nothing wrong with learning how to cope better with a health problem that can’t entirely be cured. You might just help someone else find the help they need.

Author: Murray J. McAllister, PsyD

Date of last modification: 10-30-2015

Self-Management

Often in discussions of chronic pain and its treatments, self-management gets neglected as a viable option. It gets forgotten about. Or perhaps it just never comes to mind when patients or providers talk about the ways to successfully manage pain. Instead, stakeholders in the field tend to focus on the use of medications or interventional procedures or surgeries.

Commentaries on the use of opioid medications often exhibit this lack of consideration of self-management as a viable option. For example, it’s common for stakeholders in the field to hold the use of opioids as self-evidently necessary to successfully manage chronic pain. The notion that self-management is a viable option is never even considered. Indeed, the underlying and unspoken assumption is that it is impossible to manage pain well without the use of these medications. (See, for instance, these thought leaders failing to mention self-management as an option in the face of the various crises that beset the practice of opioid management for chronic pain, here and here).

It’s an odd state of affairs for a major specialty within healthcare to persistently fail to consider, let alone promote, self-management as a viable option. Other specialty areas within healthcare don’t fail to consider the role of self-care. Think of how the fields of diabetes care or cardiology or mental health encourage and promote self-management. Such fields go to great lengths to motivate and teach patients to take ownership and responsibility for their health condition, lose weight, start and maintain an exercise program, quit smoking, eat right, manage stress, assertively resolve conflicts or other problems, and so forth.

The field of chronic pain management instead seems to subtly or not so subtly emphasize the need for patients to rely on healthcare providers to manage pain for them. How often do you hear the assertion that patients will suffer without the pain management that the healthcare system provides? With such assertions, we inadvertently proliferate a belief that it is impossible to self-manage pain well. As such, it hardly ever comes up as a viable option among the many different treatments for managing chronic pain.

Why is that?

 

Author: Murray J. McAllister, PsyD

Date of last modification: August 7, 2015

The Perfectionist and Chronic Pain: How to Cope with Pain Series

While clinical lore is that perfectionists are more prone to the development of chronic pain, it may just be that perfectionists are more likely to seek care for their chronic pain. Reason? Perfectionists with chronic pain are more prone to behavioral exacerbations of pain as well as anxiety and depression. Let’s see how.

Are you a perfectionist?

First, let’s define perfectionism. Perfectionism is a trait of an individual that involves two components:

  • Holding oneself to standards that are never quite attainable (or at least not for very long)
  • The compulsive need to nevertheless try to attain those excessively high standards.

So, the perfectionist is never quite satisfied with what he or she does and can’t seem to keep from trying to make what they do better in some way. If, on those infrequent occasions the perfectionist is satisfied, it usually lasts only until he or she sees some flaw in the original project and attempts to correct it or only until he or she moves on to the next thing on the ‘to do list.’

So what might a perfectionist look like in real life? Perfectionists tend to see how any given project might be done better. Others might congratulate them on a job well done, but the perfectionist tends to respond, either overtly or silently to themselves, ‘yes, but, this could have been done better, or if only we had more time, we could have…’ In such responses, you see the persistent lack of satisfaction with the quality of work, even when others think the quality is superior. In other words, perfectionists hold themselves to unattainably high standards, standards to which no one else would hold them accountable. These Perfectionismexcessively high standards are evident in the cleanliness and orderliness of their homes work environments. Everything has a place and is in its place. Sometimes, the unattainably high standards and the subsequent persistent lack of satisfaction come out in the quantity of work that perfectionists tend to think they should attain. They always have more to do on their ‘to do list.’ It’s hard for them to sit still, when they know that there is ‘so much more to do.’ In other words, it’s hard for them to stop their activity and simply enjoy a leisurely moment.

Notice the compulsive sense of urgency that operates with these unattainably high standards. It’s hard to just sit still and be leisurely or satisfied. Having cleaned the entire house before having guests, the perfectionist finds herself continuing to straighten up even after the guests have arrived. If the perfectionist does sit down to chat with the guests, his attention keeps returning to the one pillow across the room that’s out of place or the picture that’s hung slightly crooked on the wall. Sometimes, it’s persistent underlying tension that fuels this compulsivity – if you don’t act to fix the problem, you just get too antsy or nervous. Still other times, it’s excessive self-criticism that fuels the compulsivity – you beat yourself up in your head for having missed the one flaw and you keep at such self-criticism until you get up and fix it.

Notice that perfectionism isn’t a healthy or an adaptive way to be in the world. Despite the kudos that perfectionists tend to get from their employers or others, low-level negative emotional states tend to predominate the inner life of a perfectionist. They recurrently feel lack of satisfaction, tension, self-criticism, and time pressure (because there’s always more to do). As a result, relaxation, leisure, playfulness, spontaneity, care-free, and peacefulness are relatively uncommon experiences for the perfectionist.

Notice too that perfectionism and self-esteem are closely tied together. The perfectionist tends to mistake the quality and quantity of what they do with who they are or their worth. When what they do is never quite good enough, it’s easy to start thinking that they are never quite good enough. This dynamic further fuels the compulsivity to act to make things better: their self-esteem is riding on it. However, the compulsive actions to make the job or task at hand better is just a temporary fix. When the perfectionist puts the perfectionistic finishing touches on a job, any sense of satisfaction is short-lived, lasting only as long as it takes to move on to the next thing on the ‘to do list.’

Perfectionists are prone to all-or-nothing thinking and behavior. Because of their high standards, perfectionists tend to see only two options for engaging in any task or project: the right way or not at all. Any other way besides the right way leads to unresolved tension or self-criticism and so you might as well do it the right way right from the start. Otherwise, how can you sit still until the job is done, which means, of course, done right? It’s this kind of thinking that leads to compulsively excessive behaviors – staying up all night until the job is done or cleaning the entire house in one day or not sitting long enough to enjoy the company who came over to visit.

Over time, such all-or-nothing thinking and behavior also leads the perfectionist to be the only one who ever does anything around the house or on the team at work. Maybe initially, all the others in the family or at work pitched in. To the perfectionist, though, the quality or quantity of their work wasn’t quite good enough. So, the perfectionist felt the need to ‘finish the job’. That is to say, the perfectionist compulsively acts on his or her excessively high standards, which are of course higher than the good-is-good-enough standards of most people. At some point, the others start to catch on and think to themselves, ‘Why bother to help? She [i.e., the perfectionist] is just going to take over at some point and do it anyway.’ They may even come to resent the perfectionist for thinking that what they do is never quite good enough. If this process happens for a long enough period of time, then the perfectionist ends up with all the jobs, for the perfectionist is the only one who knows how to ‘do it right’ (at least to the eyes of the perfectionist).

Like any other personality trait, people can have varying levels of awareness or insight into their perfectionism. On one end of the spectrum of self-awareness, some perfectionists have a lot of insight into their perfectionism and can catch themselves when they get too uptight about some minor flaw. They might even be able to laugh about it when others bring it to their attention. These people, we say in the healthcare field, have ego strength – the ability to tolerate feedback about themselves and learn from it. The prognosis for these kinds of perfectionists is good. On the other end of the spectrum of awareness, some perfectionists lack insight into their perfectionism and keep compulsively trying to catch up to their inner standards without ever stopping to reflect on whether their standards are realistically attainable or not. Failing to engage in such self-reflection, they might actually see others as lazy or lacking attention to detail. They might carry around an underlying resentment that they have to do everything because ‘no one seems to do anything around here.’ In reality, though, the others aren’t lazy or inattentive, but rather squarely within the norm for quality and quantity of work. These kinds of perfectionists can therefore lose sight of the abnormal nature of their unattainably high standards and so come to see others, who hold themselves to normal – good-is-good-enough – standards, as abnormal. Such perfectionists thus can have little awareness of their own perfectionism and can in fact get defensive or irritated when it is brought to their attention. As such, these kinds of perfectionists lack ego strength – the ability to tolerate feedback about themselves and learn from it. The prognosis for these individuals is guarded.

Now, one can be a perfectionist without ever having chronic pain and one can have chronic pain without ever being a perfectionist. However, when perfectionists develop chronic pain, it’s an unfortunate combination. It lends itself to coping poorly with chronic pain. As such, they likely come to chronic pain rehabilitation in disproportionate numbers.

Perfectionism leads to behavioral exacerbations of pain

Perfectionists with chronic pain get stuck between a rock and a hard place. They experience compulsive needs to stay busy and ‘get the job done right,’ but if they do, they exacerbate their pain. If, however, they keep themselves from acting on their compulsive needs, they subsequently experience high levels of tension and/or self-criticism for failing to ‘get the job done right.’ So, they are caught between either high levels of pain or high levels of tension and self-criticism. As a result of this dilemma, perfectionists commonly go with the former: they give in to their perfectionistic needs and compulsively become excessively productive, thereby exacerbating their pain.

This all-or-nothing dilemma of perfectionism can make pacing almost intolerable. Chronic pain rehabilitation programs encourage patients to learn to pace their activities, as a way of finding the middle ground between the ‘all’ and the ‘nothing’ options. To perfectionists, though, pacing means that they have to get used to a life of not being good enough. In reality, what they might do when pacing themselves is good enough, but, to perfectionists, good enough isn’t good enough – it has to be perfect. Thus, to the perfectionist, pacing activities doesn’t seem a viable pain management option.

Perfectionism leads to chronic resting and activity avoidance

The only other option in this dilemma is to come to the conclusion that because of the pain you can’t do anything. Let’s see how this works. Suppose the perfectionist initially keeps attempting to maintain the perfectionistic standards and subsequently repetitively exacerbates his pain through the compulsive over-activity and productivity. At some point, he comes to find this state of affairs intolerable. His chronic pain rehabilitation providers have been recommending and encouraging pacing, but pacing leads to too much tension and self-criticism – living a life of recurrently failing to meet his expectations for himself. So, holding firm to his all-or-nothing perfectionism, he comes to the conclusion that if he can’t get the job done right, he can’t really do it at all. Pacing is a bogus option: there really are only two options – do it right or not at all.

As a result, perfectionists often become convinced that they can’t do anything because they can no longer do it exactly the way they used to do it.

The long-term behavioral consequence of this belief system is chronic inactivity. It leads to resting, staying home, and activity avoidance. These passive coping strategies, however, lead to de-conditioning, social isolation, a general decline of health, a worsening of pain, and increasing disability.

Now, perfectionists tend to buck at the term ‘avoidance’ above because avoidance implies choice – that they are tending to avoid activities when in fact they could do otherwise. Perfectionists thus assert that they aren’t avoiding anything, but rather they can’t do anything.

This belief in their inability to engage in their old activities is predicated, however, on having only two options for engaging in their old activities: either the ‘right way or not at all.’ If they could learn to tolerate pacing their activities, which would entail learning to tolerate being ‘good enough,’ they would find that there are all sorts of ways to engage in their old activities of life. They’d find that it just isn’t true that they categorically can’t do what they used to do. Indeed, they may just learn in their chronic pain rehabilitation program that there are all sorts of different ways to engage in the old activities of life.

Using opioids to maintain unhealthy perfectionism

Sometimes, perfectionists come to solve their all-or-nothing dilemma by relying on high doses of opioid pain medications. They maintain engaging in the ‘all’ option of the all-or-nothing dilemma by taking high doses of opioids to mitigate for the pain it elicits. In other words, they continue engaging in excessive levels of activities and productivity, which exacerbates their pain, but they compensate for it by taking high doses of medications.

This solution isn’t healthy or effective over the long-term. Most non-perfectionists would agree that using opioids to medicate behaviorally exacerbated pain is not the best use of these medications. It would be healthier and more effective to overcome the perfectionism and learn to pace. By doing so, one could get by on less medication or perhaps not even on any medication. From this perspective, we might see that the use of opioids in this way is not only a means to medicate pain but also medicate a psychological problem. Opioids are not an effective therapy for perfectionism.

From this perspective, we might also see that the continued use of opioids to treat behaviorally exacerbated pain puts the perfectionist at high risk for psychological dependence, increased tolerance, and/or addiction to opioids.

Perfectionism and anxiety

Perfectionism involves some degree of underlying anxiety. The perfectionist can’t sit still because if he did he’d become too tense or nervous or antsy. The excessive activity and productivity are thus solutions to the nervousness. It is for this reason that we consider such behavior to be compulsive. Compulsive behaviors are the behavioral antidote to anxiety – they get rid of the anxiety, but only temporarily.

We discussed above the role of ego strength when it comes to perfectionism. Those perfectionists with a high level of ego strength, who have insight into their perfectionism, can typically readily acknowledge the anxiety that underlies perfectionism. Those who struggle to maintain such insight, however, typically deny the connection. Instead, they remain convinced that maintaining perfectionistic standards is the right way to go about life.

To overcome perfectionism, one has to come to see the problematic nature of perfectionism. Once having insight into it, you subsequently have to begin the process of refraining from engaging in compulsive productivity. To do that, however, you also have to acquire ways to resolve the anxiety that remains when refraining from engaging in compulsive over-activity.

Perfectionism and depression

Depression can also become a consequence of perfectionism, especially when perfectionists never gain insight into the unhealthy nature of their perfectionism. Here’s how it works. Suppose a perfectionist remains steadfast to her unattainably high standards despite having chronic pain. She comes to see herself as persistently failing when chronic pain prevents her from attaining the standards. Persistent failure experiences lead to persistent self-criticism, which in turn can lead the perfectionist to see herself as a failure. Now, she sees chronic pain as the sole source of this recurrent sense of failure because, as we said above, she doesn’t see that her perfectionism is part of the problem. She subsequently attributes the source of her failure to chronic pain, something she has no ability to fix. As a result, she becomes hopeless. Hopelessness combined with a persistent self-critical sense of oneself as a failure equals depression.

Perfectionism as an obstacle to coping with pain well

In each of these ways, perfectionism lends itself to coping poorly with chronic pain. Of Perfectionistcourse, we are not blaming the perfectionist with these observations. Rather, the purpose is to see that perfectionism is an unhealthy personality trait that creates obstacles to coping with chronic pain well. It’s also something that can change with a concerted effort over time. Perfectionists with chronic pain learn to make such changes in chronic pain rehabilitation programs. By overcoming perfectionism, you can come to cope better with pain and as a result chronic pain becomes less problematic.

Living well with chronic pain is possible, but you have to learn how. For perfectionists, living well with chronic pain involves, at least in part, learning how to overcome perfectionism. In our next post, we’ll review common ways in which chronic pain rehabilitation programs coach patients how to overcome perfectionism.

(For more information on perfectionism in general, please see the information at Dr. Paul Hewitt’s Perfectionism and Psychopathology Lab or Dr. Gordon Flett’s video on perfectionism and health.)

Author: Murray J. McAllister, PsyD

Date of last modification: 5-3-2015

Why We Do What We Do

The Institute for Chronic Pain has a new content page on our website entitled: Why Healthcare Providers Deliver Ineffective Care. As is our custom, we announce such additions to the website on our blog and provide a little introduction to it. The content on this new page of the website is particularly important to me because providing content like it is one of the reasons why I founded the Institute. It’s not too far of a stretch to say that it’s why we do what we do. By way of introduction, then, I’d like to explain.

I founded the Institute for Chronic Pain for a number of reasons, but one of them continues to this day. Indeed, I am reminded of it most everyday.

The reason is others and mine persistent frustration over what seems like an almost endless delivery of ineffective healthcare within the field of chronic pain management. At the time of the Institute’s formation, in late 2012, the previous decade had seen an exponential increase in the delivery of procedures and therapies for chronic pain, most notably, spinal injections, spinal surgeries, and the long-term use of opioids. The use of these procedures and therapies had far surpassed the field’s traditional and empirically-supported treatment – the interdisciplinary chronic pain rehabilitation program, which had been the mainstay of treatment for twenty or thirty years by the end of the last century. For all those previous years, patients had benefited from such programs and with each decade the field had published more studies and meta-analyses demonstrating their effectiveness. In the mid-1990’s to the early 2000’s, the field began to change and change rapidly. The use of spinal injections, spinal surgeries, and opioid medications became prolific, far exceeding the use of interdisciplinary chronic pain rehabilitation programs. As a result, interdisciplinary chronic pain rehabilitation programs began to close their doors in great numbers for lack of patients.

One might consider such a sea change within the field of chronic pain management a natural progression of the field: due to scientific advances and discoveries, one set of therapies came to predominate over an older form of therapy. However, it wouldn’t be accurate.

The older form of therapy, interdisciplinary chronic pain rehabilitation programs, remained (and still remains today) the more empirically-supported treatment. In other words, such programs remain the more effective treatment and yet, as a field, we routinely deliver care that is not as effective as we could deliver – we routinely provide spinal injections, surgeries and opioid medications to patients with chronic pain, and tend to forego recommending the more effective option of interdisciplinary chronic pain rehabilitation programs. While recognition of this problem is growing and gaining momentum, this state of affairs continues to this day.

Typical responses by the healthcare system: empirical-based healthcare

Many in the field, who recognize this problem, attempt to resolve it by focusing on changing the practice patterns of providers – encouraging them to recommend less orthopedic-related care, such as spinal injections, spinal surgeries, and opioid medications, and instead recommend more nervous system-related care, such as interdisciplinary chronic pain rehabilitation.

Specifically, leaders in the field attempt to educate and persuade healthcare providers to make recommendations based on what the available scientific research tells us is most effective. This ideal for guiding the practice of healthcare is called ‘empirically-based healthcare.’ The word ‘empirical’ in this context means scientific and phrases such as ‘empirically-based’ or ‘empirically-supported’ when used in the context of treatments means that the scientific evidence supports the effectiveness of the given treatment.

This goal to have the scientific evidence for or against treatments guide our recommendations is important. It should lead the field to make more recommendations for those treatments that science tells us are effective and lead us to make less recommendations for treatments that have been shown to be less effective. Indeed, who wouldn’t argue that we should be focusing our care and resources on treatments that are the most effective?

Health insurance companies and professional provider organizations

Typically, health insurance companies or different types of provider organizations lead the drive to change provider practice patterns within the field of chronic pain management. Insurance companies periodically institute policy changes that encourage the use of empirically-supported treatments and various professional organizations develop guidelines for what constitutes appropriate care for different chronic pain conditions. In my geographical area, for instance, local insurance companies have twice attempted to mandate that patients receive non-surgical second opinions, such as psychological evaluations for rehabilitation care, before obtaining spine surgery. I personally have also served on two different guideline development committees for the management of back pain.

While admirable, these attempts never succeed in producing a significant change in the practice patterns of healthcare providers. They fight a steep uphill battle. Many of the forces for maintaining the status quo of providing ineffective healthcare on a widespread basis remain powerful and complicated. They are difficult to resolve. We discuss many of these problems in the new content page of our website.

Despite these problems, the actions of insurance companies and professional organizations are necessary. For after all, providers are an important part of the healthcare equation. They are the ones who make the recommendations and deliver the care. It’s obviously important therefore that they become convinced to recommend care that science has shown to be most effective.

While necessary, a sole focus on changing provider practice patterns is not sufficient to bring about widespread change in the field. Such a focus leaves out the role of patients who, in large measure, have a say in the care they receive. Any change to the field of chronic pain management must also focus on changing societal beliefs about chronic pain and how to best treat it.

The role of the Institute for Chronic Pain

To meet this need, we developed the Institute for Chronic Pain. While insurance companies and professional organizations play a necessary role in attempting to change the ‘supply’ side of care (i.e., what tends to get recommended by healthcare providers), the Institute for Chronic Pain focuses on changing the ‘demand’ side of care (i.e., what patients and their families expect and want when seeking chronic pain management).

Why is the latter important?

Through much of my career I have worked within interdisciplinary chronic pain rehabilitation programs. I have evaluated countless patients for such programs and a common experience upon evaluation and subsequent recommendation of the treatment is that patients refuse it.

Now there often are many reasons why people can’t or won’t pursue such a recommendation, but a common one is that the recommendation to participate in an interdisciplinary chronic pain rehabilitation program simply doesn’t make sense to them. It’s understandable given our societal belief systems about the nature of chronic pain. Many in our society understand chronic pain as something that is the result of a long-lasting orthopedic injury and as such they think that the most effective approach is to pursue orthopedic-related interventions, such as injections or surgery, that treat the spine or other joint that is the site of pain. As a result, given these societal beliefs, patients can come to refuse to participate in an interdisciplinary chronic pain rehabilitation program, in favor of seeking less effective orthopedic-related care – spinal injections, spinal surgery, and use of opioid pain medications.

To this problem, we have been actively attempting to produce content that explains how chronic pain is typically a nervous system-related condition, not an orthopedic condition, and so therefore should be mostly treated through interdisciplinary chronic pain rehabilitation. We have reviewed how the field is in the process of a paradigm shift, a change in how experts in the field understands the nature of chronic pain and what the field considers to be the most effective treatments for it. We have reviewed the contrasting ways of understanding chronic pain and have reviewed how basic science indicates that chronic pain is the result of a nervous system condition called central sensitization. We have reviewed and clarified the relationships between chronic pain and a number of the most common complicating conditions, such as anxiety, depression, trauma, insomnia, fear-avoidance, and catastrophizing; in so doing, we have explained that these conditions commonly complicate the course of chronic pain because they too are nervous system-related conditions. We have reviewed how interdisciplinary chronic pain rehabilitation focuses on reducing central sensitization and thereby such programs reduce the typical cause of pain and suffering. On our social media sites, such as Facebook, Twitter, and Linkedin, among others, we post (on an almost daily basis) news reports on published studies of the relationship between chronic pain and the nervous system, particularly the brain. In all, the Institute for Chronic Pain devotes much of its resources to changing our societal beliefs about the nature of chronic pain and how best to treat it. Our aim is to bring our common societal understandings into line with the consistent findings of the basic and applied science of pain.

In short, as our mission states, we aim to change the culture of how chronic pain is managed.

In response to these efforts to change our societal understanding of the nature of chronic pain, there remains a common reaction to which we, as the Institute for Chronic Pain, have not yet responded, at least not until now. Within the public at large, but also within the clinic when reviewing the above information with individual patients, there remains doubt that orthopedic-related care, such as spinal injections, surgeries and use of opioids, are less effective than interdisciplinary chronic pain rehabilitation. The doubt continues due to the following reason: people don’t believe it simply because orthopedic-related therapies are so much more commonly performed than interdisciplinary chronic pain rehabilitation therapies. If what we say is true – that science tells us that orthopedic-related therapies are less effective, then it would mean that the field of chronic pain management has gotten it absurdly wrong. But this conclusion, for many, seems too hard to believe. In other words, the difference between how many in the field actually practice and how science informs us that we should practice seems too incongruous to be believable.

Understandably, then, the question thus remains: ‘How could the healthcare system have gotten it so wrong? These therapies (spinal injections, spine surgeries, opioid medications) just simply have to be the most effective treatments or healthcare providers wouldn’t recommend them as often as they do.’

To this question, we put together and published the new webpage, entitled: Why Healthcare Providers Deliver Ineffective Care.

Author: Murray J. McAllister, PsyD

Date of last modification: 1-20-2015