Welcome back to the Healing Pain Podcast with Dr. Kevin Vowles
Chronic pain can bring in a thick fog that prevents us from seeing that the other side is a better and healthier version of ourselves. There are kinds of pain that have no cure for now, but Dr. Kevin Vowles and Acceptance and Commitment Therapy or ACT suggest that our thoughts don’t need to change in order for our behavior to change. This is possible through cognitive diffusion which simply means pushing your thoughts to the healing process. This makes ACT a behavioral approach to treating chronic pain. ACT helps people get a quality life that fits the patients’ needs. Dr. Kevin Vowles explains this physiological and behavioral approach to healing naturally.
It’s great to be here with you for another episode. Before this episode, I sat down for a couple of minutes and I started to write out a list of all the different ways we have to treat, alleviate, control, or numb pain. Think about it for just a moment. Think about all the different types of pills, lotions, potions, surgeries, injections, practitioners, and treatments that all claim to resolve pain. It’s quite mind-numbing after a while. If I had a nickel every time someone sent me an email or said, “Dr. Joe, what do you think about this diet or this supplement or this exercise or this energy work or tapping?”it can be really confusing, especially if what you’re looking for is the best solution for your pain. The irony is if you look at the results of all these treatments, most of them work quite poorly or even worse. More often than not, they really don’t provide lasting relief. For decades, we’ve tried to invent ways to avoid pain, to block it out, to wall it off, and for the most part we failed.
I want to begin with a question for you to think about as we settle in to our podcast together and talk with my special guest. The question is this, what if avoiding pain is the problem? If avoiding pain is the problem, is there a gentle way to begin to acknowledge the pain, to sit with the pain, and to begin to accept some of the suffering in a way that preserves your humanity, your dignity, one that’s done with compassion and empathy and might even be a little bit of fun for both the patient as well as the practitioner? ACT is an acronym for Acceptance and Commitment Therapy. This technique uses acceptance and mindfulness-based strategies, together with commitment and behavioral change strategies, to increase what is known as psychological flexibility. Psychological flexibility simply means you learn how to contact the present moment, and based on your current situation, you learn to change the behaviors that aren’t serving you and focus on the behaviors you personally choose, that guide you to what you value most in your life.
At this point, you’re probably thinking, “That is a mouthful, Dr. Joe. It sounds like something straight out of a psychology textbook.” Let me break this down for you so it’s simple to understand and it’ll give you a good segue into our podcast. If your life in any way is inhibited by your pain, this is a method that can help you move beyond your pain and redirect your focus toward what you love in life. Let’s look at it from another perspective. In life, each of us has our own inner compass. That compass is what points you in the direction of your passion, of your ambitions, your dreams, and ultimately what the greatest version of yourself can be. As an example, if you know me or my work, my inner compass is set on helping people, more specifically, it is set on helping people with pain. Each day, that compass guides my life and the momentum in my life in that direction toward things such as treating patients with pain, recording this podcast, sharing information, keeping up on the latest research about pain, and training practitioners.
For some of us, when pain enters our life, especially when it becomes chronic, it can adversely affect our inner compass and cause us to get sidetracked or lost on our way to our final destination. For some, the fog can become so thick that you can barely see what’s directly in front of you, just waiting to flourish in your life. ACT provides you with the tools to reset your personal compass for where you want to go in life, toward the things you love, and onward with the life you want to live. What I personally love about ACT is that it’s rooted in science. It’s been tested and it can often be completed in ten sessions or less. Both the data as well as what’s observed in clinical practice tells us that those with pain returned to the things they love, and that pain is no longer a limiting factor in someone’s life. That sounds like good pain care to me. To dive deeper into exactly what ACT is and how it works, I’ve invited Dr. Kevin Vowles to join me on the podcast. He is a licensed Clinical Psychologist who uses ACT in his everyday practice and conducts clinical research as to the effectiveness of ACT for pain. He’s a tremendous resource and is going to share with us why ACT is so effective and successful as well as some surprising reasons why ACT is beating out other types of cognitive therapies when it comes to treating pain. This episode is so important. When you empower yourself with the knowledge, you can set your own compass and choose the type of care you want to integrate into your life and on your specific path to healing, because everyone’s pain is unique.
How To Avoid The Trap Of Negative Thinking Using ACT with Dr Kevin Vowles
Dr. Vowles, welcome to the Healing Pain Podcast. It’s great to have you here.
Thank you for inviting me.
I’m excited because I’ve had a lot of different psychologists and mindfulness psychological approaches that we’ve talked about on the podcast, but I have yet to talk about ACT or what’s called Acceptance and Commitment Therapy. I know you use it in clinical practice and you have a lot of great research around it that supports its efficacy, so I’m super excited. ACT is new to a lot of people, both professionals as well as those with pain, who are looking for natural alternatives. Can you give us the 10,000-foot view and explain what ACT is?
There are two primary hypotheses in ACT or two primary clinical guesses. One is that there are struggles or experiences that human beings have in life that are fundamentally untreatable. In other words, these things will naturally give rise to difficult feelings, including pain. For many people who have chronic pain, that seems to be true. There are pains out there for which there doesn’t appear to be a reliable cure, at least some with chronic pain. This is the first assumption or hypothesis in the model. The second assumption or hypothesis is that it is assumed that even with these natural hard things that go on in life or these natural aversives, it’s possible to get a quality of life that is adequate for the person’s needs, is adequate for these folks to engage in activities that bring meaning, vitality, etc. to this business of life even with ongoing negative experiences or pain. Those are the two assumptions in here that bad things happen and that’s normal, and that a good meaningful life can happen even if the bad things remain.
You use the word cure, which I think is so interesting. It’s probably less so in the world of psychotherapy versus the world of physical therapy if you’re trained in a very traditional, biomechanical approach to things. You’re almost taught that you can cure things, although, we’re rapidly moving towards more of coping. Different types of psychological approaches are many out there, and many of them have the highest level of evidence as far as helping people with pain. What is the history of how ACT developed from that broad base of other psychological therapies?
The American Psychological Association maintains something called a list of empirically supported treatments listed by the Division of Clinical Psychology, and that’s probably what you’re referring to. ACT for chronic pain since about 2009 or 2010 has had strong research support which is the highest grading of evidence. For people who are interested in this, I encourage them to go to this website and see what the empirical status is for all kinds of psychological therapies. The history of ACT in pain at least, can probably be traced all the way back to a guy named Bill Fordyce who published a great book in 1976 called Behavioral Methods for Chronic Pain and Illness. Within that book, Fordyce made a distinction between problematic pain behaviors. He said the problem of pain is not just pain, it’s responding to pain too. If the pursuit of pain avoidance dominates one’s life, these so called problematic pain behaviors become a real problem and can be changed.
Fordyce said there are pain behaviors and then there are well behaviors. Well behaviors are adaptive responses to pain. Fordyce is one of my absolute heroes. The underdeveloped part of that book was what we are talking about when we’re talking about well behaviors? It was revolutionary enough talking about pain behaviors, and that was just undeveloped, that well behaviors part. Where ACT developed along a different track, mostly out of substance abuse, serious mental illness, depression, anxiety, but where it dovetails right on to behavioral treatments for chronic pain is that it really helps move forward this idea of what is a well behavior in people who have chronic pain.
As a physical therapist, the idea of well behaviors with movement obviously falls into that category is so important. When most people think of the most traditional form of psychotherapy, then they have CBT, and there’s great research around that. For social workers and other types of counselors who are exploring other ways they can help people with pain, how does ACT start to branch off from CBT a little bit but hold on to some of the great things about CBT to bring other things of value to the treatment approach?
In my fifteen years of doing this, there have only been two primary areas of distinction between ACT and CBT.As you just alluded to, they both share a common lineage, which is this behavior analysis that Fordyce’s approach was right in the middle of. The first difference is the centrality of what in ACT is called values. Values are just a word that we mean to denote areas of life that bring meaning, quality, vitality, etc. to this business of living. CBT and other psychological approaches certainly prioritize the values or other things that are values-like, but in ACT, that’s central. That gives our treatment outcome that we’re seeking, an engagement of values that are adequate for the individual. Sometimes in CBT, it is assumed that some changes happen first and then we get to values. In ACT, we get the values first and it saturates all of treatment. That’s one primary difference and that one is easily integratable into lots of psychological and other health approaches that are trying to get people to do is live effectively and meaningfully.
The second, which is more tricky, has to do with this idea of what’s the role of cognitions in determining behavior. It’s fair to say in this cognitive model that thoughts are seen as having unique causality. In other words, if we ask someone why did you engage in that behavior, what immediately precedes that and caused that is a thought. In ACT causality is defined in a more complex way, that thoughts are certainly influential on behavior, in other words, they have an influence, but they’re not the unique linchpin upon which behavior hinges. There’s other stuff in there including things like values, environment, pain intensity at the time, other feelings at the time. What we try and do in ACT is disempower thoughts and pain to the extent that the human being themselves, himself or herself, are not viewing sensations of pain or other aversive thoughts as the thing that that solely determines behavior.
It brings me back to episode eleven of my podcast where I interviewed Beth Darnall who is a great psychologist and an NIH researcher who has great studies and works specifically around a two-hour model of helping people with automatic negative thoughts or pain catastrophizing, which is central to any type of CBT approach. My question for you along the lines of ACT is does one need to think differently to change their behavior?
There is good data for psychological and behavioral approaches generally in chronic pain, and there is no evidence that any one model is knocking it out of the park. That’s probably the bottom line here. ACT or CBT don’t really have a monopoly on the right way to do it. Within ACT, the model suggests thoughts absolutely do not need to change before behavior changes. In fact, what we’re trying to do in the model is get people more loose around thinking so that we can free up behavior after thinking. Part of this is trying to normalize the negative thoughts that all of us humans have, the crazy thoughts we sometimes have. Try and improve awareness around when pain is pushing people around in an unhelpful way, and just try and broaden out the available responses to pain that this pain might go away or, in relation to cognitions, these cognitions must change or go away.
CBT is an incredibly sophisticated approach and cognitive therapy is, too. As it’s been distilled down to a level of self-help books or popular press, it’s sometimes it gets distilled down to just change your thinking. I don’t think that’s what you were saying, but it can. It runs that risk. The original cognitive works did not make it seem that simple. You see aspects of ACT in CBT where psychology wars have happened that are actually quite compatible. It’s just the one bit of wording that ACT would change is that thoughts do not need to change in order for behavioral change. In fact, we might even say behavior changes and then thoughts might change. It might be that thoughts are the trailing indicator of behavior change.
When you see a physical therapist and we start to ask you to do exercise, which brings you away from avoidance and more towards doing things that you didn’t think you could do or was going to hurt you. In some ways we bring people toward the behavior first and then the thoughts change. It’s interesting how these loops and circles develop. I teach mindfulness with patients and I love it. I think it’s a tremendous tool for people. What I really like about ACT is I find it to be really approachable for people. CBT is wonderful to me. It takes a certain mind almost to think linearly, where ACT doesn’t seem to have that same thoughts here. As a practitioner, when would someone start to say to themselves, “I’ve had this person in my class or seeing them one-on-one. I’ve been working basic mindfulness with them, and I feel like I’m bumping up against the wall.” Is there a way to objectively measure when to say, “We should start to move toward ACT,” in a way to help someone?”
The primary things I’m looking for when I’m assessing people, in relation to mindfulness, is if the purpose of being mindful is to be more aware of responding in order to respond in a different way to ineffective responses, the secret of mindfulness is just awareness. With awareness and what’s happening at the present time, behavior opens up or options open up. If I’m seeing someone clinically and they are so trapped by thoughts of pain or thoughts around pain or other problems going on in life, that these thoughts are guiding behavior or dictating behavior without any kind of awareness on the person’s behalf, that’s a great time to say, “We’re going to practice some attention training.” I won’t tend to call it mindfulness with patients just because that carries some baggage. I’d say, “We’re going to mess with attention and then see if with increased attention to how pain or other things are influencing behavior, if we can get some freedom on the other end.” One thing I look for early on is, is there a lack of awareness here? The second which is related are thoughts so dominant in someone’s behavior? In other words, are they taking over and they’re causing problems later on that we might need to do some mindfulness to try and get awareness of thoughts and loosen up around thoughts? What in the ACT model is called cognitive diffusion? In essence, it means not letting thoughts push you around as much and being aware of when thoughts are pushing you around in an unhealthy way.
Versus being fused to thoughts.
Versus being fused, which is in essence is being so close to thoughts that you got no awareness that they’re right there pushing around and making decisions for you. The last thing I look for, and this is true for all the patients I see when I assess them, is there either a deficit in values awareness of what’s important? I’m so black right now and so dire for them that they’ve lost sense of what’s important or have they never had a sense of what’s important? Sometimes people have really tough lives and they’ve just never had the opportunity to do important activities, meaningful activities. Is there a loss of awareness of what’s important, and is there a loss of success in what’s important? When those two things are present, either we go to some values awareness, what did matter or what does matter, take a guess, what could matter. Then start to do some behavior change exercises just to get people moving towards what’s important.
Can you talk to me a little bit about why language is so important when we are working and talking with patients, and why it’s really pivotal in the development of ACT and how it works?
There are at least two different levels of answers. I’ll give the most complicated one first and keep it brief. From a behavior analytic perspective, which ACT sits in, words and thoughts are a form of behavior, especially thoughts. They’re just words that are internal. They are language. Language has some unique learning processes around it that seemed to only occur in humans. In humans, we don’t need direct training around relations between languages for it to impact behavior. For example, there are frames of things that are trained up when we’re young, good things and bad things. We don’t have to have direct contact with bad things to respond to them as if they’re bad. A parent, for instance, who’s influential can tell us, “Don’t go in that dark place because it’s scary. Don’t ever go in there.”The child might never contact that, not because they’ve had bad experiences in there, but because of the language around the parents. Something called the Relational Frame Theory, has to do with the unique processes and language that have to do with learning. Learning allows us to respond adaptively and maladaptively to all kinds of situations. Clinically, what we have to be careful of in language is responding to symptoms without understanding why the symptoms are being pulled through us.
I have a PT I work with right now who’s wonderful. She was seeing a patient who was feeling nauseous, dizzy, and in a lot of pain, and immediately tried to make the person feel less nauseous, less dizzy, and in less pain. That’s what we do as clinicians. In ACT, what we would also ask in there is, “What are the things that this person is missing in her life that we’re trying to get back to? Can those be a part of the conversation to broaden out our conversation beyond symptoms to what’s important? Can we start to talk about and recognize small behavioral changes that are either occurring or that could be added to this person’s life to try and make them move in this positive direction?”This is not just a matter of ignoring the symptoms. Language is important here, but acknowledging the symptoms and their impacts, and then just trying to broaden out responding to it.
A simple form of language informing would be kids from a young age learn not to put their hand on a hot stove. They don’t actually have to put their hand on the hot stove to know it’s hot. Someone’s actually taught them that. Translating that to someone who has low back pain, many people are taught, forward bending damages your back, which is patently false. They are told that by either another practitioner or the internet or whatever. That helps to change the way they move but also starts to change the way they think on different things.
Or the old ubiquitous throwing up an MRI or an X-ray of the spine and saying, “You have a spine of an 80-year old,” or, “You have the knee of an 80-year old,” or, “You have degenerative disc disease.”The language here is super powerful. I know people are familiar with the work from the South Australians, David Butler, Lorimer Moseley. One of the key things that they’ve talked about, which is very ACT consistent here, is to be very careful with language that scares people and freaks people out, and to try and normalize this whole process and even praise it. The spine is an incredibly magical thing. It does amazing things. Our body is amazing. The key there is that this isn’t just semantic, but scary language gets frightened behavior. Positive language or normalizing language might help us normalize behavior a little bit. We have a patient right now who has a form of spina bifida. He has a “bad leg,” it’s what he’s referred to it his whole. We’ve just been working with the language on that a little bit because the “bad leg” brings with it all kinds of baggage, even cognitive baggage. “Why do I have this bad leg? It never behaves.” Even trying to change the language around that, “That leg is a trooper, it’s strong.” What we want to do is try and help it and make it stronger, has clinically allowed this person to just use the leg a little bit more, to carry less emotional baggage around it, less scared about it, less angst about it. It freed up behavior a bit.
I had Lorimer Moseley on the podcast. He talks about language. He also talks about metaphor, which is really important. ACT really delves into metaphor in a really beautiful way and really starts to expand upon it. Can you explain how metaphor is used in ACT to help people?
We talked about fusion and diffusion in that fusion, in a way, is cognitions and language dominating behavioral responses. Metaphor allows us to teach a principle, just like metaphors and parables, since written language began. it allows us to teach a lesson that offers people a perspective that is relevant to how they’re responding to pain. For instance, in ACT, there is a metaphor called the passengers on the bus. The basics of it are that we’re driving through life on a bus and all the passengers on the bus are the thoughts and the feelings that we carry along with us, the memories that make us, us. These thoughts, feelings, and memories come up to the front and they give us driving directions every now and again, in a good way and in a bad way and in a neutral way.
The passenger from the back comes up and says, “Tie your shoes in the morning,” and that’s useful advice. At the back of this bus are the harder things in life that we carry with us, and sometimes they come up and give us unhelpful orders. We talk about this in treatment as the pain guide. The pain guide will sometimes tell us what to do in helpful or unhelpful way. Sometimes, they come up from the back and we make deals with them essentially, and we say, “If you go in the back so I don’t have to see you anymore or look at you, I’ll just keep doing what you tell me to do.”Fear does that, and anxiety, when it becomes problematic depression, or things like that. The key clinical message here is that we live up to our end of the deal, which is we do what they say, what these passengers order us to do, but they don’t live up to their end of the deal. They don’t go away. In fact, they remain and become bigger. Some of what we’re talking about thoughts and feelings in that metaphorical story way can allow is the effective response that could sometimes be so uncomfortable. Sometimes it decrease it a bit, just offer people some perspective on these things and some are noticing of how they’re ordering one around.
Metaphor is so important when we work with patients. Definitely Lorimer has gone into it and he has these one-liners that I think are amazing. In the ACT work that I’ve read, there are beautiful stories and people really connect to story in a way that is human. We use story in our life every day and in psychotherapy as well. I definitely want to talk about your research because I’m interested to know where we’re going. Before we go there, I want to put something out there that’s quite simple that I think will help anyone who’s a patient, anyone who is struggling and that’s the serenity creed. For those who don’t know the serenity creed, it says, “God grant me the serenity to accept the things I cannot change, courage to change the things I can, and the wisdom to know the difference.” It’s been obviously popularized by some of the 12-Step Programs to do rehab from drugs and alcohol, but why is that almost a good synopsis of what ACT teaches?
There’s a second part of that which is often not the part you find and it makes it better. There are a number of psychological approaches that have their core that humans who are suffering have two choices, to persist or change. There’s an approach called Dialectical Behavior Therapy, which a behavioral treatment for a pretty hard to have condition called borderline personality disorder. The dialectic in Dialectical Behavior therapy is essentially that when one is behaving in a way that’s not working, then you either keep behaving in that way or they can make a change. In ACT for chronic pain, what we ask people to look at first is what have you done to try and solve this problem of pain, and has it worked? How has it worked? In some ways it’s worked. Behavior analysis will stop if it wasn’t working in some ways.
Often these pain control efforts in folks who have chronic pain who have had it for a long time, they do some good things short-term. They reduce pain. They reduce the stress. They can give people hope. They can make people feel like they’re taking action and doing something. The long-term consequences are almost always fairly problematic. The pain gets worse, the stress gets worse, disability gets worse. Important life roles like relationships, family, independence, start to suffer. Part of the reason why we start there is that people have a choice to keep trying to solve the problem of pain, so to persist or to change, to do something different. If you have this conversation clinically with someone and they’re buying it and they’re following, the question that always follows is, “I don’t want to persist. Tell me what to do, “which is a hard one. The three guiding principles here in change are at least do something different. That is an unsatisfactory answer, but at least we got to get that. We can’t have the same. If we do different things, we might get different things. The OTs I used to work with in the UK had this phrase they love to say, which is, “If you keep doing what you’ve always done, you’ll keep getting what you’ve always gotten.”
The second is that we try and do is look at important areas of loss in life and say, “There might be some guidance in this loss,” which hurts people. It makes them sad. If family relationships, independence, and hope are suffering, individual agency, we might build a structure treatment to change explicitly in those areas. The interdisciplinary rehabilitation programs that I’ve been a part of and that I’m a part of now, that’s day two of the treatment that we introduced. That treatment is explicitly about that. The third part here is for us as clinicians to think about this too. We have an incredible amount of skills regardless of discipline and we have the opportunity to persist or change when we’ve got someone for whom something isn’t working. We have all had the experiences beating our head against the wall. It’s not working. Sometimes, because we don’t know what else to do, we just keep trying it. That is not useful.
The fourth option is to highlight for people that they always have the opportunity to try to increase their awareness that there are behavioral choices that are always available when responding to aversives. This persist or change thing, you don’t have to sign it in blood that you’ll never do the old thing again. There’s great time to avoid pain and there’s great times to not avoid pain. What we want folks to be able to do is to be in a position of effective decision-making. This gets back to mindfulness that we assume with a bit of awareness of what’s going on at present, a bit of awareness of what one desires, short-term and long-term, come the ability to make more effective decisions.
You have a really great body of knowledge and when it comes to looking at ACT in chronic pain as well as other areas. What are you excited about right now in your research and what are you starting to discover that is probably coming down the pike for us?
I’m reasonably satisfied at present with the evidence of ACT for chronic pain. In other words, the body of knowledge suggests that it works reasonably well for most people. We have some data that came out that suggests that these treatment-related improvements are not dependent on improvements in pain or pain-related distress. That’s really important for us as clinicians. It doesn’t mean we don’t care about pain or distress, but it means we don’t have to move those hard to move things in order to get good treatment outcomes. The areas where there is a need for expansion within ACT, and even more broadly in psychological behavioral approaches, our ability to predict who will benefit remains chance. We can assess as much as we want and it’s darn hard to predict who’s going to benefit. It’s hard to predict who will sustain benefit. At the end of these intensive programs we run, we go through all the people we’ve seen and I often think, “This person’s all set. He’ll be fine. This person’s not all set. Treatment didn’t work here.” Then when we see him at follow-up in three months or twelve months, again, it’s chance. This is a broad problem in all of it where we got to get better at that. We’re trying to work on predictive models to see who is likely to have continued benefit.
The second big a thing I’m excited about and worried about and all of this, is that here in the United States as well as in other countries, we have this issue of opioids at present which I’m sure everybody’s familiar with. This issue of opioid use is so nuanced. In the old days, opioids are bad. This is what a guy named Bob Kerns, a very well-known psychologist in CBT. He says, “I’m old enough to remember when opioids were bad, and then they were good, and now they’re bad again.” In the United States, we have a population of patients or a subpopulation of people with chronic pain who also have this issue of problematic substance use on top of that. We have no adequate treatments that address these two things that are going on. We have some studies running right now. In fact, we’re collecting the last follow-up data for a trial to see whether or not an integrated ACT treatment for chronic pain and problematic opioid use does useful things. This is a huge issue. The secondary problem of opioid use is that some of these people who are in trouble are following medical advice to the T. These are not folks who are getting it illicitly or illegally. We’ve got folks who rightfully feel quite irritated with the medical system that the medical system started this problem and is now trying to solve this problem by taking all the goods away. Alongside that, we have a lot more heroin on the streets these days. We have a little bit of data coming up that there’s an awful lot of co-use of alcohol and other sedatives with opioids, and that there’s this huge risk for overdose and fatalities.
As a field, we got to work on trying to sort this one out. What are we going to do with these folks? Methadone maintenance historically is primary treatment for heroin, to help people come off of heroin and stay on methadone forever to decrease withdrawal. At our current university methadone clinic, 80% of those folks seem to have chronic pain. If you ask them, an intensity of 4 or more on a 0 to 10 scale. It’s been around for longer than three months and it’s having an impact on functioning. Of that 80%, it seems like just under 80% started on prescription opioids. It doesn’t show up in the pain clinics. This is a sample at the methadone clinics. That’s both scary and exciting. There’s room to improve. This is not a research challenge, but this is a United States challenge. We can as a field really take advantage of the problems that opioids have caused, which is to try to make very coherent arguments for the reestablishment of behavioral therapies in the treatment of chronic pain.
Early on, opioids were marketed as equally efficacious and cheaper than interdisciplinary care. The evidence base does not seem to support that assertion at this point. What I mean by interdisciplinary care is real interdisciplinary care, multiple disciplines offering an integrated model of treatment, not different disciplines under the same roof doing their thing. What we’ve been doing here in New Mexico, were in the fourth week of the first interdisciplinary pain rehab program, the fourth of six weeks. The states never had one and these interdisciplinary programs were decimated in the early ‘90s. There’s a chance for a resurgence of this. What us, clinicians need to do is get literate in funding codes and try and see if we can pull something together that offers a treatment adequate to the complexity of chronic pain and that also allows us to keep the clinic lights on. The opportunities are there. That’s not really a research one, but that’s more of a pragmatic one.
Everything you said is profoundly important. I have a client I’m working with right now who is not only trying to get off opioids, but she’s also on a benzodiazepine. You know more than I do how difficult this is going to be. It’s not impossible at all, but there has to be a tremendous amount of support that is built around this person. The message is getting out there that these drugs really don’t have their place. I’ve become a lot more vocal about it as I’ve done this podcast and as I’ve talked to both you as well as patients, them not having their place. We’re starting to wean people off these medications. We’re just pulling the rug out under them without any kind of support at any level. You said something about integrative care, which I want to just circle back to. There are interdisciplinary clinics where there’s a psychologist, physical therapists, an OT, a physician, a nurse. One of the things that I talk about is that yes, we need more integrative interdisciplinary clinics. However, with 100 million people who have chronic pain, we have a huge problem that we’ve ignored for a long time. One of the approaches that I really start to look at is you may live in a small town in New Mexico where you’re the only let’s say PT or you’re the only psychologist, and now you have this person in front of you that has multiple behavior changes that are needed for them to move beyond their pain. How does that fit into what you said?
It’s such a great point and such a challenge. The golden fleece that everyone’s working after right now or trying to get to is how to disseminate this out to the rural areas where there is not the opportunity to come into contact with a highly skilled team. I wish I had the adequate answer. One potential answer is for us as clinicians, as policy makers, and as researchers to do our best to identify needs for level of care and to advocate for needs for level of care. We have a study that we’re examining an app right now. ACT for chronic pain is the big thing and that’s going to be for the low-end of complexity, although it’s high-end of disseminable. It’s on the app store for people who are in the states.
If we can get good as clinicians that triaging people to levels, we might be able to more clearly direct people to higher levels of care. Where we need to be careful in this is trying to do our best and take all comers when we know that what we’re offering is going to be inadequate to the complexity. That can sometimes have an iatrogenic effect. Not a big one. We’re not killing anybody. No one’s overdosing on it. It just cannot do people huge favors. I worked in the UK in interdisciplinary care for eight years. We set up a service in the midlands of the UK, just South of Manchester, called the IMPACT Service and it was about half the dose of what other programs tend to be in the UK. It was the first one that have ever been set up there. It was a rural area that’s a bit like Detroit. It’s called Stoke-on-Trent, a strong industrial background and then a complete collapse of the industry. We were the only service provider for complex chronic pain that was interdisciplinary. We decided at the beginning to take all comers because we knew if we didn’t take all comers, that they’ve had nothing.
What our data suggests is that the folks who had the highest levels of physical disability that couldn’t walk, over 20 or 25 meters in a five minute space, they’re often wheelchair bound because of pain, these folks dropped out treatment at a five-fold rate, and if they did complete treatment, they get a lot worse than the people who could start treatment walking higher. We compared our findings with the other more intensive progress in the UK, which is a very good program in Bath that I worked at for a while. Bath has a program that’s about twice the intensity. Our gains are about equal on psychosocial stuff, pain acceptance, engagement, and values-based activity that are about 60% of the impact on physical functioning. We continue to struggle with this and that program to this day. I wish I knew the solution. Long-term, if we can try and at least get people at the right level of care or at least advocate for it, knowing that the most expensive integrated care is going to be just the tip of the pyramid. There won’t be too many people that we can do what we want to do as clinicians, which is give people back the limit and functioning.
Those programs you talked about, are they in-patient programs or out-patient programs?
They are mostly out-patient programs. In the UK, they’re called pain management programs or pain rehabilitation programs. Bob Gatchel in the US called them comprehensive pain rehabilitation programs, which I think is a great title for them. They tend to be outpatient these days. The program in Bath has an inpatient program. They run about four or five times a year, and that’s for the most disabled folks, the folks who are bedbound, so primarily outpatient.
What do you really want to work on the next couple years as far as looking into ACT and piecing something out of it?
The big one is trying to treat co-morbid substance problems, including opioids and other things. What that has required of me and clinical psychologists that have been practicing for twelve years is to try and go learn from my colleagues here in the pharmapsychology, to learn about substance use treatments because it is not ever a part of my treatment. It’s so relevant. That’s probably the biggest thing that we’re trying to work on in ACT. The second biggest is trying to identify what an adequate dose of training is for folks. This is a big issue, too. When is it done with fidelity and when is it not? Motivational interviewing researchers have a great body of literature on this. In Psychology, they’re far ahead of everyone else. A study that they did suggested that a workshop with Bill Miller, one of the founders of MI, didn’t change behavior, reading a book by Bill Miller, the founder of MI, didn’t change behavior. The only thing that really changed behavior was training plus structured follow-up with the trainer where there was individualized feedback. Just speaking of dissemination issues, that’s a hard one to disseminate. That would be a great one for us to try and get sorted out within the next ten years.
It so important that we make sure of that. As people start to discover ACT and so to embrace it that we figure out, “What’s the right level of training?” Steven Hayes did a wonderful thing in saying that ACT is really open to everyone to learn, and the ability for it to spread and help. Then it’s like, “How much do I really need?” If I’m a psychologist, I probably need less than an RPT, for instance.
What RPTs have done, in essence, they use training and physical activity, training and biomechanics and proper movement as a vehicle to get people doing values-based activity. That is so easy to integrate right into. If you have a psychologist around, let them do the talking and trying to do diffusion work, and then you can follow up on that. RPTs also talk about paying attention to quality movement. It’s about mindfulness exercise. Notice when quality starts to go down. I came to ACT through behavior analysis and the thing that attracted me to ACT was the clarity of focus on values and how this is not discipline-specific. This is generalizable across disciplines and how deficits in values-based functioning are one of the things that tie all sources of human suffering together. It gives us as clinicians a vehicle to pursue our treatment agenda, which is to help people. That is a non-controversial part of ACT. There are plenty of controversial parts of it, that’s non-controversial.
Ultimately, the goal with this podcast and everything that we do as pain professionals is to help people cope better, move them toward things they value in life, and then ultimately lead them to a life where they have the least amount of suffering possible.
There you have it, an approach to living life with chronic pain unlike you’ve ever seen before, and one that helps you move beyond the pain instead of trying to control it, dominate it, or completely avoid it. Pain is an experience each of us deals with throughout life. It’s part of being human. Pain is known as a protector, but when it turns chronic, it becomes more of a preventer, preventing you from living the life you love. That’s why ACT is poised to continue to grow and help those with chronic pain.
To discover more about ACT, make sure to download the free ACT Starter Kit right now that I created, especially for you by going to www.DrJoeTatta.com/75Download. If you’re on your cell phone, you can text the word ’75 Download’ to the number 44222. Inside, I provide a full explanation of what ACT is, a few metaphors you can use, as well as some of the amazing research by our expert guest, Dr. Kevin Vowles. As you leave the podcast, make sure to hop on to iTunes and subscribe to the healing pain podcast. May you live your life with ease. May you live your life to the fullest and may you live your life with the least amount of suffering possible. I love each and every one of you. Thank you for being here with me.
About Dr. Kevin Vowles
Kevin Vowles completed his PhD in clinical psychology at West Virginia University in 2004 and post-doctoral fellowship at the University of Virginia the following year. From 2005 to 2009, he was employed in the United Kingdom by the Centre for Pain Research and Services at the University of Bath and Royal National Hospital for Rheumatic Diseases. Beginning in 2009, he accepted a position to provide psychology leadership in developing a novel interdisciplinary pain rehabilitation program delivered interface of primary and secondary care interface with Keele University.
After three years of trial funding, this program was deemed by the UK’s National Health Service to be highly effective in both clinical and financial terms and permanent funding was secured. This service was awarded with the National Care Integration Award in 2012. That same year, Kevin moved to the Department of Psychology at the University of New Mexico, where he is currently an Associate Professor, to continue his work in the development and evaluation of treatment methodologies for those experiencing chronic pain and illness. He has been working in the field of chronic pain and illness for the majority of his career and has published over 70 articles in the area since beginning his doctoral training in 2001.
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