Kevin E. Vowles, Ph.D. - PowerPoint Presentation

Slide1

Kevin E. Vowles, Ph.D.Department of Psychology28 May 2015

Living a Valued Life with Chronic PainSlide2

4 Questions

What is valued living?Slide3
Slide4

Is “life uninterrupted” the goal?

If so, how are we doing?Slide5

Chronic Pain

Common

e.g.,

Breivik

et al., 2006,

Gureje

et al., 1998

Persistent

e.g.,

Andersson

, 2004; Elliott et al., 2002 Gureje et al., 2001Has a extraordinarily widespread impact on lifeE.g., Fordyce, 1988; Gatchel et al., 2007

Pain remains

Pain remains

Pain remainsSlide6

Figure 7: The

impact of chronic pain on daily activities.

27%

47%

43

%

30

%

61%

48%

47%

54%

72%

73%

65%Slide7

Also, durable

and

problem-free

pain reduction is pretty darn hard to achieveSlide8

Opioids

-

No supportive evidence for long-term pain reduction (i.e., > 15 weeks).

Martell et al., 2007 – Ann. of Internal Medicine – Systematic Review

Chou et al., 2007 - Ann. of Internal Medicine – Clinical Guidelines

Surgery

-

Continued pain and disability are the norm following spinal surgery (i.e., discectomies & fusions).

Franklin et al., 1994; Hoffman et al., 1993; Turk, 2002; Turner et al., 1992; 1995

Spinal Cord Stimulators - Pain reduction is relatively transient (absent @ 3, 4, & 5 year f/u). No evidence of improvement in functioning or quality of life.

Kemler et al., 2000 NEJM; 2002 J Neurosurgery; 2006 NEJM; 2008 J Neurosurgery

Epidural Steroid Injections – Lumbar -

“Probably not” effective for long-term pain relief, improving functioning, or decreasing rates of surgery.Cervical

- No evidence available upon which to base a conclusion.

Armon

et al., 2007., Neurology – Systematic Review & Clinical Guidelines commissioned by the Amer. Acad. of NeurologySlide9

“As a guiding principle in my life: (Importance of area rated)”

Assessed 36 samples (

n = 159 – 295 in most samples)

across 20 countries

Multidimensional Scaling of termsSlide10
Slide11

4 Questions

What is good living?

Do people with pain want good living?Slide12

!Slide13

Excerpts from patient letter:

“trying to do more to take load off of husband/daughter”

“If there are no carers and I’m bad, I don’t wash, eat, etc.”

“(Pain is) ok, but neck hurts, tight chest and cough, starts in spine, pins/needles in arms/hands”

“I can cope with the pain . . . but clumsiness and weakness is dangerous!”

“the house is a mess, (husband) is stressed/depressed, (daughter) stays away”

“I’m very positive and cheery (driven) and I think it does me no favours as I think people think I am ok”Slide14

4 Questions

What is valued living?

Do people with pain want valued living?

What is the clinical rationale for valued living

with

pain?Slide15

Clinical Rationale

Valued living

:

Only happens when

valued living

happens.

See Vowles, 2015, Introduction to Special Issue on Modern Behavior Therapies,

Current Opinion in PsychologySlide16

The problem of pain can be

conceptualized as one of

behavior

(not of pain).

The problem with this behavior

is that it is often directed

towards pain control and

away from areas that bring

meaning and importance

to living.

1976!

2014!Slide17

Goal and Assumptions

Valued living

:

Only happens when

valued

living happens.

Does not require feeling

better, good, happy –

or being

pain free

.Is about having options for behavior - AKA a “broad behavioral repertoire”

See Vowles, 2015, Introduction to Special Issue on Modern Behavior Therapies, Current Opinion in PsychologySlide18

“I can’t go on”

Thought

Action

Stopping

Context

Overwhelmed by private content

Unwillingness to

Experience

Valued

Behavior

FailuresSlide19

“I can’t go on”

Thought

Action

Stopping

Context

Willingness to

experience

Contact with

thoughts &

wider experience

Persistence

i

n values-based

a

ction

Carrying

on

orSlide20

4 Questions

What is valued living?

Do people with pain want valued living?

What is the clinical rationale for

valued

living

with

pain?

What do the data have to say?Slide21
Slide22

Does it work?

“To meet this standard,

well-designed

studies conducted by

independent

investigators must converge to support a treatment’s efficacy.”Slide23

Possible prerequisites for change?Slide24

Improved willingness to have the

experience of pain

+

More frequent engagement in valued activity over the longer term

=

(should)

WITH

PainSlide25

The impact of

more willingness

and

more

values-based activity

Better:

Current

emotional and physical functioning

Vowles & McCracken, 2008, Health Psych; Vowles et al., 2008, Pain;

Vowles & Thompson, 2012; Vowles et al., CJP; Vowles et al., 2014, Beh Ther

Future

emotional and physical functioning

McCracken & Vowles, 2008,

Health Psych;

Vowles et al., 2011

, BRAT

Improvements in emotional and physical functioning in the months and years following treatment Vowles et al., 2007, Eur J Pain; Vowles & McCracken, 2008, J Consult Clin Psych; Vowles et al., 2011, BRAT; Vowles et al., 2014, J Pain; Vowles et al., 2014 J Contextual Beh PsychologySlide26

Treatment Success?Slide27
Slide28
Slide29

From: www.flickr.com/photos/-leethal-/4296360438/

Connecting the dots . . .

In at least some patients, at least some of the time, pain no longer appears to be the paramount problem.

In responding normally to pain, behavior can be directed towards pain control at the expense of areas that bring meaning and importance to living.

Treatment methods can:

directly target these losses and restrictions in living.

work towards willingness to have the thoughts and feelings associated with them in the service of improving living.

measure outcomes in terms of successful living, not severity of symptoms.Slide30

“People who have something

better to do don’t suffer as

much.”

-

Wilbert Fordyce (1988)

“Friendship in adversity”, Ray Byrne, http://www.flickr.com/photos/raybyrne/363881679/Slide31

Thanks for your attention.

Questions?

k.e.vowles@gmail.com