Kevin E. Vowles, Ph.D.

Department of Psychology

28 May 2015

Living a Valued Life with Chronic Pain

4 Questions

1. What is valued living?

Is “life uninterrupted” the goal?

• If so, how are we doing?

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., 2001

• Has a extraordinarily widespread impact on life• E.g., Fordyce, 1988; Gatchel et al., 2007

Chronic Pain

Adult Population

1 yr

4 yr

12 yr

0% 20% 40% 60% 80% 100%

Pain remains

Pain remains

Pain remains

Figure 7: The impact of chronic pain on daily activities.

27%

47%

43 %

30 %

61%

48%

47%

54%

72%

73%

65%

Also, durable and problem-free pain reduction is pretty darn hard to achieve

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

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

• “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 terms

4 Questions

1. What is good living?

2. Do people with pain want good living?

!

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”

4 Questions

1. What is valued living?

2. Do people with pain want valued living?

3. What is the clinical rationale for valued living with pain?

Clinical Rationale

Valued living:

• Only happens when valued living happens.

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

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!

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 Psychology

“I can’t go on”

Thought Action

Stopping

Context

Overwhelmed by private content

Unwillingness to Experience

Valued BehaviorFailures

“I can’t go on”

Thought Action

Stopping

Context

Willingness to experience

Contact with thoughts &

wider experience

Persistencein values-based

action

Carryingon

or

4 Questions

1. What is valued living?

2. Do people with pain want valued living?

3. What is the clinical rationale for valued living with pain?

4. What do the data have to say?

Does it work?

“To meet this standard, well-designed studies conducted by independent investigators must converge to support a treatment’s efficacy.”

Possible prerequisites for change?

Improved willingness to have the experience of pain

+

More frequent engagement in valued activity over the longer term

=(should)

WITH

Pain

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 functioningMcCracken & 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 Psychology

Treatment Success?

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.

“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/

Thanks for your attention.

Questions? k.e.vowles@gmail.com