Transcript Using Creative Hopelessness to Break the Treatment Failure Cycle

Using Creative Hopelessness
to Break the Treatment Failure Cycle
Edmund A. O’Connor, Jr., Ph.D.
Director & Chief Psychologist
The Pain Center at
(616) 233-3480
Acceptance & Commitment Therapy
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“The single most
remarkable fact of
human existence
is how hard it is
for human beings
to be happy.”
“Suffering is a
basic
characteristic of
human life.”
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There is an
assumption that there
is a healthy normality
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Language is at the
core of human
suffering
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Goal: to interact
differently with pain
and what our mind
tells us
The Pain Center at
What is “Acceptance”?
Pursuit of valued life activities in the
presence of pain
Recognizing pain may not change,
therefore a change in life is needed
Lack of negative thoughts and
emotions
Optimism during pain
Recognizing that the suffering
may not change
Living in the present moment
Not needing to avoid or control pain
Optimism regarding the future
Good pain coping skills
A sense of control over pain
Willingness to remain in contact with and actively experience
both good and bad private events
What’s the Goal of Treatment?
Values
Acceptance &
Commitment
Therapy
Vitality
Intimacy
Productivity
“eh!”
Traditional Medical
& Psychological
Models
Disability
Anxiety
Stress
Depression
ACT and Chronic Pain
Fear of future health and
finances; loss of past
health and function
Pain focus;
lose sight of
values
Pain
avoidance &
struggle for
control
Strong belief in
negative and
catastrophizing
thoughts
Efforts to
control pain
dominate at the
expense of
valued action
“ I am a pain sufferer”
& all that goes with it
The Pain Center at
ACT and Chronic Pain
FearContact
of futurewith
health
the and
finances;
of past
presentloss
moment
health and function
Acceptance
Pain
of pain and
avoidance
&
emotions
…
struggle for
willingness
control to
feel and
experience
Strong
Defusion
belief in
negative and
Detach from
catastrophizing
painful thoughts
thoughts
and emotions
Values
Pain
focus;
lose
sightofof
Clarity
values
what is
meaningful
Psychological
Flexibility
Committed
Efforts to
control
Action
pain
dominate at the
Behavior
expense of
reflects values
valued action
Self as Context
“ I am a pain sufferer”
is only
small
& Pain
all that
goesawith
it
part of who I am The Pain Center at
ACT is …
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"What we've been talking about is kind of like the show
"Fear Factor." The stuff that the contestants do on that
show are really crazy. No one would every jump off a
bridge or eat a bunch of cow intestines for no reason. It
wouldn't make any sense to put yourself through all that
pain. But it's a different story when you could get a
million dollars for it. These people actually choose all
that pain and yuckyness because it could be worth a
bunch of money. I guess that's what living according to
my values is like. I might choose to be in pain for the
things that matter to me."
The Pain Center at
Failed Treatment Cycle
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What does it look like?
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Why does it keep going?
The Pain Center at
Failed Treatment Cycle
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“The more our health care system
helps us to avoid unpleasant feelings,
the less we tolerate them, the more we
believe it is abnormal to have them,
and the more we do.”

Dahl & Lundgren, 2005
"Ill health is abnormal and unnatural. Health is your birthright and the normal, natural state of your body."
Yours in Health,
The Pain Center at
Failed Treatment Cycle
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The biggest reason - we are taught
discomfort is bad, so we treat it as we would
genuine illness
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“It is how the person reacts to the symptom, rather than
the symptom itself that determines health seeking
behavior, disability and sick-listing”
“It is not that pain itself has increased—rather our
willingness to accept pain that has decreased.”
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Why the shift? Pain used to be unavoidable, and thus
was accepted, now we can avoid it better, so we don’t
learn to tolerate it
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We keep trying to control our pain
The Pain Center at
Pain Relief
Pain Willingness
Acceptance of the
Unworkability of Control
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95% solutions
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When I get rid of pain, I can have “X”
Why we stick with it
 It works elsewhere
 It seems to work for others
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You are told it should work for you
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“My friend had this surgery and …”
Repeatedly try medications, PT, shots, etc.
“I don’t know why you still have pain.”
“It’s all in your head.”
It even SEEMS to work short run
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Drugs work ... But at what cost?
Patients care about pain right now
The Pain Center at
Acceptance of the
Unworkability of Control
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“If you don’t want it, you got it.”
Metaphors
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Tug of war with a monster
Feed the tiger
Chinese finger trap
The Pain Center at
Acceptance of Where You Start:
“Creative Hopelessness”
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Not a feeling. Context from which futile
struggles are seen for what they are and
behavioral change is possible.
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The client’s first exposure to all six ACT
processes and the ACT therapeutic stance
 Assessment of ACT targets
 Examine workability
 Validate the client’s experience
The Pain Center at
Creative Hopelessness: How To
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Can range from almost psychoeducation to
gut wrenching processes of clearing the field
for a person who is deeply stuck
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Key questions:
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How has that worked for you? It must be genuine!
How has that worked long term?
Where has it worked / not worked?
Is this familiar? Have you tried that before?
Is your life bigger or smaller?
Does this seem like a “rigged game”?
The Pain Center at
Acceptance of Where You Start:
“Creative Hopelessness”
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You’ve tried about everything
Suppose your experience is valid? Suppose it
won’t work
Metaphors
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Man in the hole
Looking in the fridge
Desire to control keeps showing up
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Dig stairs, etc.
Oyster pearl
The Pain Center at
Pain Treatment Experience
Type of Pain
Treatment
Short-term
effects on pain
Meds
some relief
Surgery
total relief for a
short time
Alcohol
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some relief
Long-term
Long-term effects on
effects on pain
Quality of Life
None
Couldn't teach
None
Great for a while, now
back where I started
None
Sick every morning;
wife is mad
Do not judge or encourage
Refer back to long-term effects when
they seek to go down the same path
The Pain Center at
Creative Hopelessness: How To
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In your reactions subtly cast the issue in experiential
avoidance terms – What are they trying not to feel?
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Admit partial success of control efforts; go small if full
success is claimed; tie back to QOL
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Be careful not to get hooked by content (agreement;
disagreement; need to understand; shifting topics;
attacks, etc.)
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Sign of progress – silence, humor, starts and stops,
lightness
The Pain Center at
Creative Hopelessness: How To
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Remain curious. Hold assumptions of experiential
avoidance lightly.
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Avoid convincing, no attempts to prove pain avoidance is the
problem
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Don’t get caught up in content.
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Sit with uncertainty and confusion.
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Watch for picking up the shovel.
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Remain on equal ground and focus in the moment.
The Pain Center at
Great! They’re Hopeless …
Now What?
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Identify what they value
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“What do you really want?”
“If pain weren’t an issue, what would you be
doing?” “Why?” (Why gets at value)
Attending Retirement Party or Funeral
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Can they be willing to bring pain along to get
what they value?
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Watch for avoidance and fusion
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It will show up
The Pain Center at
Great! They’re Hopeless …
Now What?
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Match treatment to values
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How will drugs (or surgery, or …) get you
“(value)”?
Watch for attempts to control
Sadness in effort is ok ... It is hard!
Refer when:
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Truly hopeless
Cannot identify values
Heavily invested in what their mind tells them
The Pain Center at
“So what can I do?”
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Prioritize valued living
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Discuss side-effects and
pain management in terms
of cost to valued activities
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Avoid “You need to accept it”
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Enlist patient commitment to
valued function as a priority
because it is what they want
most (i.e., if you didn’t have
pain – what would you be
doing?)
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Honesty about
hopelessness
Avoid pain relief as the
primary goal unless it is
acute and realistic
At least tie them into
pursuit of values
Control the controllable
Normalize pain flare-ups
Refer those who are
stuck or trapped in
dysfunctional thinking
and distress
Committed Action
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What I value is …
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What I’ve been doing is …
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“Closeness with my wife and kids”
“Checking-out, lying in bed or in front of TV”
What it cost me is …
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“My family. How can I have a relationship like that?”
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“I am through with that”
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My commitment is …
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“Have dinner with my family, no matter how I feel … I miss them”
The Pain Center at