Teaching Self-Management of Chronic Pain with Acceptance and Commitment Therapy. Cheryl Meyers, LCSW, MAC Oregon State Hospital

Transcription

1 Teaching Self-Management of Chronic Pain with Acceptance and Commitment Therapy Cheryl Meyers, LCSW, MAC Oregon State Hospital 1

2 Objectives Introduce the theoretical foundation of Acceptance and Commitment Therapy (ACT) Describe 3 ways that Acceptance and Commitment Therapy can be utilized within a medical and mental health model List 3 ACT centered approaches that can be used when working with clients who have chronic pain 2

3 Disclaimer The intent of this talk is not to help you understand everything there is to know about ACT Theoretical underpinnings are important, but so is being able to apply skills (even one or two) in the brief office visit or patient interaction 3

4 What is ACT? ACT (Acceptance and Commitment Therapy) is a 3 rd wave school of therapy that comes out of Behaviorism and CBT. Acceptance of current circumstances without judgment Identifying value based goals Implementing strategies to attain these goals 4

5 ACT is a therapeutic approach that uses acceptance and mindfulness processes, and commitment and behavior change processes, to produce greater psychological flexibility. - Steven Hayes 5

6 What is Psychological Flexibility? the ability to contact the present moment more fully as a conscious human being and to change or persist in behavior when doing so serves valued ends. Steven Hayes 6

7 ACT Evidence Based Practice Recognized on Substance Abuse and Mental Health Services Administration (SAMHSA) National Registry of Evidencebased Programs and Practices Listed on the State of Oregon Website as a recognized evidence based practice 7

8 ACT Protocols and Research Agoraphobia Psychosis Sleep Problems Anxiety PTSD Depression Substance Abuse Developmentally Disabled Couples Epilepsy Pain Management Diabetes Management General Therapy Anger Management OCD Post-Partum Depression Skin Picking Trichotillomania Weight Maintenance Worksite Stress and Burnout 8

9 History of ACT First Wave Behavioral ACT comes out of a branch of behaviorism know as Radical Behaviorism Radical Behaviorist essentially view that everything that an organism does is behavior Thus to a radical behaviorist thinking, feeling, and remembering are all forms of behavior RB s also talk of two realms of behavior (public and private events). 9

10 History of ACT Second Wave- CBT Stretched beyond operant theories of overt behavior to deal with thinking Major emphasis on challenging and disputing irrational, dysfunctional, or negative thoughts 10

11 History of ACT Third Wave- ACT, DBT, MBCT More emphasis on function rather than the form of problematic behaviors or symptoms. Emphasis on more experiential and indirect change methods 11

12 3 Pillars of ACT Acceptance and Commitment Therapy Accepting instead of rejecting experiences (open) Chosen instead of Automatic Behavior (aware) Taking action instead of Being Acted Upon (engaged) 12

13 The Aim of ACT ACT is not aimed at making people feel better feelings and think better thoughts. ACT is aimed at helping people live better lives. *where better is gauged by the extent to which people are living lives that are consistent with their values. 13

14 The average mind has about 10,000 thoughts a day. 14

15 General Guidelines Your mind is not there to make you happy Your Mind is not your friend or your enemy The mind evolved to protect you from danger BUT it relentlessly creates verbal representations of events relating everything to everything often arbitrarily and sets up the illusion that a thought = the actual thing or event If thoughts are what they say there are, then we are at the mercy of every arbitrary thought that arises In ACT the word mind is actually a metaphor for human language. (words, images, sounds, physical gestures all are symbols in language.) 15

16 Traditional Therapy In traditional approaches (medical, counseling) it is the intensity, form or presence of symptoms that is presumed to be critical Treat the symptoms before 16

17 Symptom Reduction Humans natural tendency is to avoid problems (something we don t want) Our tendency is to figure out how to get rid of it or avoid it. This serves us well in most instances. Example of getting rid of problems: There is a ferocious tiger outside the door to this room: Example of avoiding problems: Windstorm 17

18 General Guidelines In ACT, the focus is not usually on symptom reduction. Acceptance Mindfulness Suffering 18

19 ACCEPTANCE 19

20 Acceptance Being present and resolved in circumstances as they are without judgment. Opening up and making room for feelings as they are, not as they say they are. Acceptance is giving up hope for a better yesterday 20

21 What Acceptance Is and Is Not Acceptance is NOT Tolerating Resignation Defeat A less than alternative Passive Acceptance IS Openness without defense Dropping judgment Making room for feelings 21

22 Expansion The word Expansion can be used in place of Acceptance Expansion is an understandable and visual word There are fewer reactions to word expansion vs. acceptance. 22

23 Acceptance and Pain Important for dealing with chronic pain. As we currently understand chronic pain we do not have the treatment to stop it (or it wouldn t be chronic) Lack of acceptance can lead patients to have the expectation that the only successful outcome is freedom from pain 23

24 Acceptance and Pain Requires mindfulness or living in the moment, something that chronic pain patients may have difficulty with Lack of mindfulness can cause patients to define who they currently based on the past or future, attaching labels which dictate behavior and self identification Lack of mindfulness can lead to catastrophizing, projected disability and amplified pain behaviors 24

25 Lack of Acceptance Patients tend to get stuck in chronic pain expecting that where they are is only temporary and do not accept that chronic pain is chronic. Patients often place blame and power with others, believing that the cause and solution is explainable and within reach What I can do now is replaced by What I did and What I will be able to do 25

26 Commitment 26

27 Commitment In commitment there is no I ll try Willingness is the primary condition for committed action Willingness is not wanting to take action, it is an act of choice. A decision will only lead to action if it is bonded to a commitment. It takes a deep commitment to change and an even deeper commitment to grow. Ralph Ellison 27

28 Commitment and Pain Refocuses patients on values and current capabilities to live congruently with them Changes focus from disability and limitations to abilities and ways to move toward values 28

29 Commitment and Pain Challenges black and white thinking My pain is 10/10 Nothing helps I am not able to do any of the things I used to 29

30 6 Core Processes Control and Creative Hopelessness: Understanding the cost of efforts to solve the problem. Full emotional contact with their discomfort. The situation isn t hopeless but their efforts to control it have been Values : as a guide De-fusing language: Making room for acceptance. Noticing rather than getting caught up in our thoughts. Willingness and Acceptance: 30

31 Fusion: When a person is fused he cannot discriminate his subjective description of reality from reality itself. Does not recognize this is an opinion. Additionally when fused with a thought that forms a rule the person follows the rule as if it is an order. Defusion: State of relationship to a thought whereby a thought can be observed without behaving according to it s literal meaning. Being able to look at life the way life actually is. not as your mind says it is 31

32 Fusion and Defusion Continuum There is a continuum of an individuals relationship to a thought.. 32

33 Do Our Chronic Pain Patients Become Fused? What would you think if it were something else? Do they balk? That would be great vs What do you mean something else. Don t you believe me? You may be dealing with Fusion Many of us become Fused to some degree in our lives.. 33

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35 Creative Hopelessness Hopelessness the Belief is irrelevant to ACT. We are not asking the clients to believe the situation is hopeless. We are asking them to contact their own experience of the futility of the struggle even while their verbal programming does it s thing 35

36 Willingness/Acceptance Presented as an alternative to trying to control Quicksand metaphor and Chinese Finger Traps Psycho-educational myths (what it is and isn t) Motivational Interviewing 36

37 Values 1.Values are Here and Now, Goals are in the Future 2.Values never need to be justified, they are simply statements about what is meaningful to us. 3.Values do not have an end point 4.Values are freely chosen 5.Sometimes you have to drill down deep to find the value 37

38 How do I start to use ACT with my clients? Notice what is happening in the here and now Practice willingness to have experiences Clarify chosen life directions (values) 38

39 Tools for the Clinician: (Creative Hopelessness) What have you tried to get rid of your symptoms? Did you succeed in permanently getting rid of them? What has this pursuit cost you? Has this brought you closer to the way you want your life to be? 39

40 Tools for the Clinician Address pain avoidance behavior Ask the question, how would your life be different if you were to? Would you hurt more, and if so would it be worth it? -Observe that many pain avoidance behaviors end up worsening pain in the long run 40

41 Tools for the Clinician (Defusion) Is this thought in any way helpful? Am I going to believe my mind or my experience? Is this an old story? Have I heard this one before? 41

42 Tools for the Clinician (Willingness/Acceptance/Commitment) Not a promise Not a prediction Not an attempt to be perfect Doing what is in one s best interest in a given situation. 42

43 Tools for the Clinican (Values) What sort of person do you want to be? How do you want to (act, be) in the world? What would you like people to say about you when they toast you at your 80 th birthday? 43

44 Tools for the Clinician Avoid patient-illness fusion Avoid negative labels! Fibromyalgia patient vs. patient diagnosed with fibromyalgia Back Pain sufferer vs. person with chronic backache Recognize that every person is different, but point out that they are not universally unique 44

45 Tools for Clinicians Do not ignore patient stories, but point out that we have absolutely no power over the past or the future, only on the exact moment that we are in. Can be challenging-patients often define themselves by their stories when it comes to pain Focus on the now decreases suffering, a major confounding factor with chronic pain 45

46 ACT and Chronic Pain Protocols Mid-Valley Pain Clinic (503)

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