1. Edmund A. O’Connor, Jr., Ph.D. Director & Chief Psychologist The Pain Center at (616) 233-3480 Using Creative Hopelessness to Break the Treatment Failure Cycle

2. Acceptance & Commitment Therapy “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.” There is an assumption that there is a healthy normality Language is at the core of human suffering Goal: to interact differently with pain and what our mind tells us The Pain Center at

3. What is “Acceptance”? Living in the present moment Pursuit of valued life activities in the presence of pain Lack of negative thoughts and emotions Willingness to remain in contact with and actively experience both good and bad private events Optimism during pain Good pain coping skills Optimism regarding the future A sense of control over pain Recognizing pain may not change, therefore a change in life is needed Not needing to avoid or control pain Recognizing that the suffering may not change

4. What’s the Goal of Treatment? “eh!” Stress Anxiety Depression Disability Values Vitality Intimacy Productivity Traditional Medical & Psychological Models Acceptance & Commitment Therapy

5. Fear of future health and finances; loss of past health and function ACT and Chronic Pain Pain avoidance & struggle for control Strong belief in negative and catastrophizing thoughts “ I am a pain sufferer” & all that goes with it Pain focus; lose sight of values Efforts to control pain dominate at the expense of valued action The Pain Center at

6. ACT and Chronic Pain Pain avoidance & struggle for control Strong belief in negative and catastrophizing thoughts “ I am a pain sufferer” & all that goes with it Pain focus; lose sight of values Efforts to control pain dominate at the expense of valued action Acceptance of pain and emotions … willingness to feel and experience Defusion Detach from painful thoughts and emotions Psychological Flexibility Self as Context Pain is only a small part of who I am Committed Action Behavior reflects values Values Clarity of what is meaningful Fear of future health and finances; loss of past health and function Contact with the present moment The Pain Center at

7. ACT is … "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

8. Failed Treatment Cycle What does it look like? Why does it keep going? The Pain Center at

9. “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 Failed Treatment Cycle "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

10. Failed Treatment Cycle The biggest reason - we are taught discomfort is bad, so we treat it as we would genuine illness  “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.” 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 We keep trying to control our pain The Pain Center at

11. Pain Relief Pain Willingness

12. Acceptance of the Unworkability of Control 95% solutions  When I get rid of pain, I can have “X” Why we stick with it  It works elsewhere  It seems to work for others “My friend had this surgery and …”  You are told it should work for you 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 Drugs work... But at what cost? Patients care about pain right now The Pain Center at

13. Acceptance of the Unworkability of Control “If you don’t want it, you got it.” Metaphors  Tug of war with a monster  Feed the tiger  Chinese finger trap The Pain Center at

14. Acceptance of Where You Start: “Creative Hopelessness” Not a feeling. Context from which futile struggles are seen for what they are and behavioral change is possible. 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

15. Can range from almost psychoeducation to gut wrenching processes of clearing the field for a person who is deeply stuck Key questions:  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”? Creative Hopelessness: How To The Pain Center at

16. You’ve tried about everything Suppose your experience is valid? Suppose it won’t work Metaphors  Man in the hole  Looking in the fridge Desire to control keeps showing up  Dig stairs, etc.  Oyster pearl Acceptance of Where You Start: “Creative Hopelessness” The Pain Center at

17. Pain Treatment Experience Do not judge or encourage Refer back to long-term effects when they seek to go down the same path The Pain Center at

18. In your reactions subtly cast the issue in experiential avoidance terms – What are they trying not to feel? Admit partial success of control efforts; go small if full success is claimed; tie back to QOL Be careful not to get hooked by content (agreement; disagreement; need to understand; shifting topics; attacks, etc.) Sign of progress – silence, humor, starts and stops, lightness Creative Hopelessness: How To The Pain Center at

19. Remain curious. Hold assumptions of experiential avoidance lightly.  Avoid convincing, no attempts to prove pain avoidance is the problem Don’t get caught up in content. Sit with uncertainty and confusion. Watch for picking up the shovel. Remain on equal ground and focus in the moment. Creative Hopelessness: How To The Pain Center at

20. Great! They’re Hopeless … Now What? Identify what they value  “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 Can they be willing to bring pain along to get what they value? Watch for avoidance and fusion  It will show up The Pain Center at

21. Great! They’re Hopeless … Now What? Match treatment to values  How will drugs (or surgery, or …) get you “(value)”?  Watch for attempts to control  Sadness in effort is ok... It is hard! Refer when:  Truly hopeless  Cannot identify values  Heavily invested in what their mind tells them The Pain Center at

22. “So what can I do?” Prioritize valued living Discuss side-effects and pain management in terms of cost to valued activities Avoid “You need to accept it” 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?) 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

23. Committed Action What I value is … “Closeness with my wife and kids” What I’ve been doing is … “Checking-out, lying in bed or in front of TV” What it cost me is … “My family. How can I have a relationship like that?” “I am through with that” My commitment is … “Have dinner with my family, no matter how I feel … I miss them” The Pain Center at