Managing Chronic Pain - Patrick Davis, PhD

Dr. Sechrest: Hello, I’m Dr. Randale Sechrest, your host for eOrthopod.TV. Today I have as my guest, Dr. Patrick Davis. Dr. Davis is a clinical psychologist who works with chronic pain patients. Dr. Davis holds a PhD from the California School of Professional Psychology in the Bay Area Campus. Thanks for joining us.

Dr. Davis: Thank you for having me.

Dr. Sechrest: Dr. Davis, what I’d like to talk about over the next 30 minutes or so is the role of clinical psychology in the evaluation and treatment of chronic pain. I think that in this day and age it is very common for chronic pain treatment centers to be multidisciplinary in nature, to have psychologists, physicians, nurse practitioners, pharmacists, different types of practitioners that try to bring their specific expertise to bear on patients with chronic pain. So let’s start out by talking a little bit about the disease process – chronic pain – in general. Can you help me understand a little bit about what the difference between treating chronic pain and treating, for example, pain as a symptom, pain is acute pain in a patient who has pain as a symptom of another disease process? What’s the difference in those two conditions?

Dr. Davis: Well, I think that’s is most helpful to understand that difference, by thinking about the difference between acute health problems more generally, and chronic health problems more generally, because the difference in treating acute versus chronic pain parallels the differences that you would find between an acute illness such as the flu and a chronic illness such as diabetes. So we don’t want to set patients who have chronic pain out as being somehow different from all other patients. They’re actually quite similar to patients who have other types of chronic health problems. Now there’s really quite a bit of overlap between treatment interventions that one might use with a patient who has acute pain and patients who have chronic pain, but the main difference really has to do with lifestyle and self management types of interventions which, to a large degree reside within the capabilities of the patient himself. So behavioral medicine or psychological treatment of patients with chronic pain focuses often on identifying those types of issues for that patient and helping the patient learn how they can enhance their skills with regard to self management of the illness of chronic pain.

Dr. Sechrest: It’s interesting. I think every physician has had the experience of suggesting that a patient with some type of illness that, maybe or maybe not is behavioral in nature, but have made the recommendation that they see a clinical psychologist. It’s very clear that we do this almost routinely when we’re treating chronic pain patients, and expect the clinical psychologist to be an integral part of the treatment team. But the one response from the patients, a lot of times to the physician, is that, “well, you must not believe that I’m really in pain” for example, “you may think that this is all in my head”; and it takes a lot to debrief the patients, so to speak, to get them thinking in a different way. How do you deal with that situation when we, as physicians, have sent patients and they show up in your office, and maybe, they think they’re in the wrong place?

Dr. Davis: Well, I think you’re absolutely right and that’s an initial hurdle that a mental health professional that works with any patient that has a chronic health problem has to be alert to on the first occasion that the patient comes to the mental health professional’s office, and may have to try to de-bunk or diffuse negative attitudes about the referral for that very reason. And despite the fact that the physician who has made the referral may have done everything that they can do to try to persuade the patient that the referral doesn’t mean that the physician thinks that the illness is all in their head. Quite often, when the patient comes to my office, they still really kind of believe that that’s what’s going on. So, to get more directly to your question, I find that I need to spend a fair amount of time explaining to people that the treatment of chronic illness is really quite different from the treatment of acute illness and when people develop chronic health problems, including chronic pain, that there’s often many behavioral sorts of issues that tend to exacerbate or make the pain problem worse. Along the same lines, there are attitudes that people may develop about chronic pain where they’re really thinking about their pain as though it were an acute illness or some sort and that leads to the types of behaviors that a person would exhibit in response to an acute illness, but those behaviors become maladaptive when the pain persists. The underlying attitudes that drive those behaviors need to be identified so that we can work on trying to change those attitudes. Then there’s just the very way in which people cope with illness and, in this case, with chronic pain. The thoughts that they have about their chronic pain when they’re experiencing a flare-up of pain or the feeling states, the emotions that they experience. One thing that we know very well from the scientific research is a person’s emotional state can influence the magnitude of the pain that they experience. So certain emotions can magnify or enhance the pain perception while other emotional states can tend to dampen down or reduce pain perception. In any event, I try to explain to patients that it’s really not about this idea that the pain is all in their head but rather that the chronic pain experience involves more than just the sensory component of the pain, it also involves behavior, attitudes, thoughts, and emotions; and if we’re able to identify areas along those lines, that may be problematic for that particular patient, then we can teach them skills to manage those aspects of the onus of chronic pain so that they hopefully, through their own self management efforts, can begin to reduce the overall net pain experience.

Dr. Sechrest: It’s interesting. You’ve laid out, I think, a very ambitious project here in terms of understanding the whole treatment of chronic pain. I think we, as physicians, are always at risk for simplifying or oversimplifying a condition and viewing primarily as a mechanical sort of thing so we’re always looking for what’s wrong of the machine of the body and why have we not been able to fix this. Why have we not been able to fix this? Why have we not been able to find the right medication, the right injection, or maybe the right surgery in order to make this machine function the way that we think it ought to? I think that what you’ve just laid out is a much more complex picture of any chronic disease and, especially chronic pain; and that is probably we, as physicians and we as patients, are wrong if we tend to think of this as a purely biomedical disease-that it’s just a problem with the physiology and if we just get the physiology of the body is a machine correct, everything should be fine. So, explain that a little bit more to me. I don’t think it’s quite that simple.

Dr. Davis: I think you’re absolutely right, and it goes back, again in a sense this dovetails with your earlier question about the patient coming with the misconception that they’ve been referred because the physician thinks that the pain is all in their head. One of the early interventions that we can do is to teach the patient about the difference between the traditional biomedical viewpoint on health and wellness; and the newer biocycosocial view point. It’s a transition that’s often referred to as a sort of paradigm shift in terms of the patient’s attitude, and really, for that matter, in terms of the attitudes of a treating health care providers as well because the biomedical viewpoint is so entrenched. That biomedical viewpoint does tend to be very reductionistic and looks for a one-to-one correspondence between something that’s causing an illness, and then what the cure or the treatment is for that one cause. But with chronic illness, what happens is as people continue to respond to a chronic illness with behaviors and attitudes that are appropriate for an acute illness, as time goes by there are all kinds of secondary problems that start to develop because of the way in which they’re trying to manage their illness is not working. So they’ll develop, well, financial problems if they’re not working, they may often develop relationship problems. There are self-esteem problems that develop. If people have had some difficulties with personality functioning or with anxiety or depression but not particularly serious issues in the past, those issues then can become more pronounced and aggravated. So this chronic illness problem, this chronic pain, becomes much more than a simple reductionistic biomedical type of situation. It becomes a very complex situation that comes to involve not only the underlying pathology, which is generating the pain in the first place and which, by the time they come to our program, may well have been healed or stabilized. But it also comes to incorporate all kinds of problems in the patient’s social universe, their psychological functioning in terms of anxiety or depression and behavioral patterns that they pursue. So if we want to treat the patient who has a chronic illness and, in this case, chronic pain effectively we have to have a more complex and a more comprehensive approach to assessment. Then based on what we find during that assessment, a more comprehensive and more complex approach to the treatment, and unfortunately, it isn’t very simple and reductionistic, it’s more sort of complex.

Dr. Sechrest: Well, let’s sort of delve into a couple of those different points. One is, you mention that like any medical problem or psychological problem or anything else, the first step is to really understand what you’re dealing with, and that’s assessment, that’s evaluation. That’s where we both, I think, do information gathering to try to understand what the components of the illness are. Then once we feel like we’ve got a pretty good understanding of it, then we start to look at the possibility of creating a long-term treatment process, to try to get that patient in a much better place. It may include physical changes as well as behavioral changes, things that we do from the standpoint of medications, injections, surgery, those sorts of things, and things that the patients may learn to do for themselves like these behavioral changes. So let’s start with the assessment from the psychological standpoint. If I’m a patient and I’ve been referred to you for a psychological evaluation because my physician has decided that I am now a chronic pain patient or I have a problem with chronic pain, and he’s referred me to you, how do you start that process of evaluation?

Dr. Davis: Well, we try to start the evaluation process really before I ever see the patient. We have some prepared written materials that are provided to the patient that we hope that they will read. Then, before people come to see me for the initial assessment interview, I have them complete a number of relatively brief paper and pencil questionnaires. Then again, along with that package of paper and pencil questionnaires, there is some written information that hopefully gets them thinking along the kinds of lines that we’re trying to think along and that we’ve been talking about so far today. The package of questionnaires that I have people fill out is designed to specifically assess things which have been evaluated in scientific literature and shown to be relevant to the chronic pain experience. So there are things such as fear avoidance or catastrophizing or muscular bracing, things like that that are unique to the chronic pain patient which are assessed by these questionnaires. We also assess a patient’s level of anxiety and depression because that’s important in a couple of different respects. In any event, once they’ve completed this package of questionnaires and I’ve had an opportunity to score those tests and review that information then I’ll meet with the patient for what amounts to about a 2 hour interview during which time I learn as much as I can about the history of the patient’s pain syndrome, the current status of that syndrome, how the pain affects their life at the current time, learn as much as I can about the patient’s personal background and I also talk with them about anxiety and depression and other types of mental health issues. Once that’s been accomplished then I’m able to do a couple of things, I think, that are helpful in terms of the overall treatment planning. The first would be that if the patient is having very significant problems with anxiety or with depression, we may need to identify that and get treatment in place to address those issues before we can really focus too much on helping them to manage their pain because those issues may be just so salient and overwhelming that they really just require initial treatment. If that is done, or if that’s not really the case with the particular patient, then this other set of what I would really refer to as relevant clinical characteristics that we’re trying to assess – the fear avoidance, the catastrophizing, the maladaptive belief patterns, and maladaptive behavior patterns – through the interview and the testing process, we’re able to identify a number of those types of things which may be causing problems for the patient in terms of their efforts to manage their pain as effectively as they can. Having identified those types of things, then we can construct an individualized treatment plan for that patient that will be sure to address those specific types of issues.

Dr. Sechrest: I think that a lot of patients have this somewhat of a fear because I think that there is a stigma still associated with the treatment of mental health issues and that sort of stuff and patients really, from my standpoint, tend to be somewhat suspicious when we’re trying to send them to a mental health worker, a psychologist, etc. I think what you’ve just laid out, clearly, is not anything that I would consider onerous or anything that a patient should be concerned that somehow they’re giving away very private information that they should be concerned about giving away. That’s not the nature of this intervention as you’ve just explained it.

Dr. Davis: For the most part that’s absolutely true. Most psychological or behavioral medicine intervention and chronic pain these days focus around an approach to treatment to as cognitive behavioral therapy or CBT. That approach to treatment really focuses on people identify problematic cognition or the way that they think about things and learning to think about things in a different kind of way – that’s the cognitive component of cognitive behavioral therapy. Then there’s the behavioral component and that’s helping people identify the ways that they do things, lifestyle kinds of things, that might be making the problem more difficult for them and helping them to change those types of behaviors. So these are fairly straightforward, here-and-now kinds of things. It’s not really a traditional, old-fashioned, Freudian psychodynamic where you lay on the couch and free associate about all the skeletons in your closet sort of approach to therapy. Although, with selected patients and certain situations, that approach to treatment may be helpful but that’s not the predominant approach. It’s a much more straightforward, nuts and bolts, rational-seeming approach to treatment.

Dr. Sechrest: If I could put you on the spot, I’m going to ask you a very pointed question, and that is, as a psychologist dealing with chronic pain, what do you see as the top issues that affect a patient’s well-being from the psychological standpoint? Their ability to cope with their disease? What do you see as the real issues with those patients that you’re going to focus in on when you do an initial evaluation?

Dr. Davis: Oh, gosh, there are several, but there are a few that I think are most salient and that we see most frequently. I think a primary one is this issue of whether or not the patient can wrap their mind around what we call a biopsychosocial attributional style, and that means to relinquish that biomedical perspective. . . it’s not really to relinquish the biomedical perspective, it’s more of an enhancement where you’re adding in an appreciation for psychological and social factors as well as biological factors. I think it’s so important for patients with chronic illness to adopt that biopsychosocial attributional style. What I mean by attributional style is just that when they have a flare-up of chronic pain, if we’re talking about chronic pain patients, that they look back over the previous week or couple of weeks and they try to identify not just what happened physically or think about what might be going on in their body that’s causing that flare-up, but also look at they’re behavior, look at the level of stress that they’ve been experiencing and see whether or not those types of things may be contributing to this variation in their pain. So that biopsychosocial attributional style, I think, is one of the most important things. I think another very important issue that’s been receiving increasing attention in the literature just in the last 5 years or so is this issue of fear avoidance. Quite often, when people have chronic pain, they become fearful of moving their bodies or of engaging in certain types of tasks, and when they do that, what happens with time, is they become increasingly deconditioned, and, with that, movement just because increasingly painful and a vicious cycle sort of ensues. So we want to teach people about fear avoidance or we want to identify whether or not that’s an issue for a given patient, and we want to keep a focus on that as a part of their ongoing treatment. If they’re involved in physical therapy, we want their physical therapist to be aware of that so that kind of fear avoidance doesn’t obstruct optimal outcome. Another real important issue, is this issue that I mentioned earlier of catastrophizing which is the type of emotional reaction, or it’s a type of emotional reaction that a chronic pain patient may have when they experience increased pain. Without going into a great deal of detail on what catastrophizing is, it’s a way of thinking which basically tends to be very nonproductive and very focused on the idea that this situation is very terrible, that there’s nothing that anybody can do about it, and that it’s never going to get better. The problem is that when people process information in that way or when they experience those types of emotional states, that has the effect of enhancing their experience of pain. Again, of course, it creates another one of those vicious cycle types of scenes. So, those are three very primary issues. I guess one more that I would add is helping patients to focus on increased function and helping them to understand that when they have chronic pain, it’s unlikely that any type of treatment program is going to get rid of their pain completely; and what the true objective should be is to bring that pain as low as possible and keep it on a level playing field so they’re not having a lot of ups and downs from day-to-day. But, in addition, to leveling out the playing field, even though they’re left with some degree of baseline pain, their level of function can gradually increase with time if they engage in physical activity in an appropriate way. So we want to help them to adopt the view that a good outcome in their life is not just merely finding a cure for their pain, but is rather getting that pain under better control, and gradually increasing their level of functioning in the world so that they’re able to increase their overall quality of life.

Dr. Sechrest: I think it’s probably worth pointing out is that these things, like catastrophizing, fear avoidance, lack of an understanding of this biopsychosocial focus, all of us have some of these attributes in our way of dealing with the world everyday. It’s not like that patients who exhibit these are abnormal in some way. All of us have these different attributes, some more than others, but we need to learn to be aware of it and need to learn how to interpret what we are doing when we’re faced with these barriers to managing any chronic illness whether it’s weight loss, stopping smoking, chronic pain, diabetes, like you say, all of us share these attributes.

Dr. Davis: You’re absolutely right and that’s because our default way of viewing illness is according to the acute illness or the biomedical model. So, if you’ve just broken your leg, to engage in fear avoidance is entirely appropriate. A little bit of catastrophizing probably isn’t going to hurt you in that particular situation, and seeking a biomedical solution to that problem is the appropriate thing to do. The problem that happens when people develop chronic illness is that they continue to engage in those behaviors and those emotional and cognitive responses that are appropriate for an acute incident, but they become maladaptive when the problem becomes a chronic problem.

Dr. Sechrest: Well, as we move on towards crafting a treatment program for folks, once you have a pretty good understanding over a period of time where a patient is in terms of all of these different things, the catastrophizing, the fear avoidance; how do you begin to work with that patient to get them to in some ways diminish some of these negative things and accentuate the positive things? So how do you move a patient from a point of more dysfunction into a more functional lifestyle? How do you do that as a clinical psychologist?

Dr. Davis: Well, I think the short answer is that we just teach the necessary skills. If we go through the comprehensive initial evaluation process we’ll have identified whether or not this particular patient tends to catastrophize or tends to have a lot of fear avoidance. Whether or not they have difficulty with pacing their physical activities well. Whether or not they have a lot of chronic tension that they maintain in their muscles and various other sorts of things and as I said before it’s really an individualized approach to treatment. For each particular patient, some of those issues may be present or they may not. But for the patient that they are present for then we want to teach them skills that they can use to manage those kinds of issues. In a sense that’s putting the answer to your question a little bit ahead of the true answer though because, getting back to the issue of the concern that patients have that working with a mental health professional somehow means that they have acknowledged that the pain is all in their head. Quite often patients are reluctant to some degree to learn these kinds of self management things and I think a lot of that comes from this idea that if they start doing something that the mental health professional suggests in their mind it seems to them that that’s an acknowledgement that the pain is not real. That it’s imaginary. That it’s all in their head. So we really have to assess whether not a patient is going to be open to learning these types of self management skills and strategies that we can teach them and so that’s one thing that we do. Another thing that we assess during the initial evaluation process is we try to determine whether or not a patient is even open to learning about this kind of information. If the patient is not open to learning about that kind of information, if they’re resistant, then it’s going to be a waste of their time and a waste of our time to spend a lot of time teaching them these skills. So we try to identify those patients, and we approach their treatment in a different way. It’s a more sort of educational approach where we provide them with education about how things could be different if they were interested in learning these skills. Tell them stories about other patients who perhaps were like them from this initial attitude of not really being open to self management but who started with following a methodology that we suggest for pacing their physical activities, or learned how to de-catastrophize or got around fear avoidance kinds of issues and how they got their pain under better control and how the quality of their life improved. But beyond that type of an educational intervention, we probably won’t try to do a whole lot with those folks. We’ll let them know that we’re available to them in the future if they think that at some point they would like to take advantage of the things that we have to offer them if they feel motivated to try to implement those things in their life. But the course of treatment for those individuals will tend to be relatively brief unless they come back at some point in the future, which a lot of them do, and say, “Okay. Now I’m ready.” For the people who are more ready to learn this material, then we provide either individual or group focused interventions which, again, tend to be largely educational but also somewhat experiential in nature where we will teach people to identify when they’re engaging in catastrophizing types of thought processes. We’ll work with them in terms of the specific types of behaviors they tend to illicit, fear avoidance behavior, or provide them education about pacing, and we’ll teach them good relaxation skills. By relaxation skills what I’m talking about is what some people also refer to physiological quieting. A way of calming the activity of the central nervous system and achieving a deep state of relaxation in the muscles and there are many approaches to that, and so in our group program that we have at St. Pat’s we kind of provide a survey of a variety of different approaches to relaxation because not everything sits real well with everybody. In any event what it boils down to is a fair amount of education, providing experiential exercises when we can, and then encouraging people to go home to try to implement these things in various ways in their lives to see whether or not it makes the difference for them. If they have sufficient motivation and they go home and they implement these things in their lives, invariably they will come back and they will talk about how they’re beginning to manage their pain more effectively, how their benefitting from these self management types of interventions.

Dr. Sechrest: I think we should point out to patients too that this does require some degree of work and commitment on their part. I think we’re all used to coming in for, again, that episodic illness sort of approach where we know we’ve got a kidney infection, or a sore throat and we’re just there to get that prescription and in two weeks this is going to be gone. The things that you’re talking about really take time to build on and take time for the patient to become proficient at so that they really will give you the benefits you and I, I would assume, feel that they should get from these benefits, and this is a matter of weeks to months that this goes on. I think we’re an impatient society and we want results today.

Dr. Davis: I think you’re absolutely right. In fact, I think it’s an ongoing process much more beyond months. I think if a person really gets on board in terms of trying to improve the quality of their life despite the fact that they have chronic pain, there’s a lot they can achieve in a matter of weeks or months if they’re motivated. But I think it’s an ongoing process. It goes on really for the rest of their life. It has a parallel, I suppose, in what people refer to as just being a learning person in general. There are people who, in their lives, they’re always striving to learn ways to improve the quality of their lives and improve their level of functioning whether they have chronic pain or not. Whether they have chronic illness of any kind or not. It’s a fundamental mindset that a person can have about how they live their life. So, for example, if a person has learned good relaxation skills, a person with chronic pain has learned good relaxation skills and they find that it helps them to reduce muscle spasm or even prevent muscle spasm. They find that it helps them to get back to sleep when pain wakes them up in the middle of the night. They might learn that in a matter of weeks or months. But, over the course of the next couple years they can continue to refine that skill so that it works better and better for them as time goes by.

Dr. Sechrest: Well, this has been a fascinating discussion about the role of clinical psychology, especially the treatment of chronic pain, but any chronic illness. Anything that we haven’t covered during this discussion that you think patients should know about the role of the psychologist and the behavioral medicine specialist when we’re treating chronic pain?

Dr. Davis: Well, the behavioral medicines specialist or the psychologist, I think, is also helpful in providing input to the rest of the treatment team with regard to the intricacies of working with a particular patient from time to time, so there’s that. But I think if we’re coming close to closing here and if I was going to add one last thing that I think is just so important for patients, that is, one of the things that we actually begin, we have a pain school program, at St. Pat’s and that’s a group program that meets for a number of weeks. In one of the early sessions, one of the things that we focus on is values – identification or perhaps it’s re-identification – of what a person’s personal values are. What’s important to the patient in their life whether that’s family, recreation, or social activities, or spirituality, or creativity, or intellectual pursuits. It’s different for different people, but we try to get people to become clearly aware of what their personal values are in life and we recognize that minimizing the amount of pain that they experience is an important value. But we want them to see where that value fits in the overall hierarchy of values because what happens so often with chronic pain is that that particular value, reducing or avoiding pain, somehow floats to the top of the values hierarchy and eclipses other things that are very important. And it’s that very dynamic that is an important component to the depression that a lot of people with chronic pain feel because their not living their living in a manner that’s consistent with the things that are really important to them. One thing that I try to emphasize to patients with chronic pain is if they work through a comprehensive approach, a multidisciplinary approach to treatment of their chronic pain, one thing they can do is identify what’s truly important to them about their life and put the avoidance of pain, and the seeking a cure of pain in the proper perspective so that it’s not preventing them from pursuing the other values that are very important in their life. A metaphor that I frequently use is that of driving the bus and who’s driving the bus – is the pain driving the bus, you know this is the bus of life – so is the pain driving the bus or is the patient, the person, driving the bus and is the pain somewhere in one of the backseats back there. Quite often, when people first come to my office or when they first come to our program, the pain is clearly driving the bus, and we want to help them get in touch with their values so that they can get back in the driver’s seat and they can put the pain back in one of the seats in the back.

Dr. Sechrest: Well, I think that’s an excellent metaphor and an excellent place to close. Very good advice. Thank you very much.

Dr. Davis: Thanks.