Innovations in Chronic Pain Management · Innovations in Chronic Pain Management Mark P. Jensen,...

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Innovations in ChronicPain Management

Mark P. Jensen, Ph.D.University of Washington, Seattle, WA, USA

Wednesday, April 20, 2016ASCH Webinar

Disclosure

- Author of two books on the topic of this workshop,

- Receive royalties from the sales of those books

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- Provide a neurophysiological model that can be used to guide hypnosis assessment and treatment,

- Model two specific strategies

- Questions and discussion

Webinar Goals and Overview

Facilitate a shift from this…

My pain is

horrible manage-able

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To this…

My pain is

horrible manage-able

And to this…

Sensations are

horrible safe

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And from this…

My life is

horrible meaning-full

To this…

My life is

horrible meaning-full

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Sensations are

horrible safe

My life is

horrible meaning-full

BIS and BAS

BIS BAS

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BIS and BAS

BIS BAS

Behavior (e.g., Approach, Goal-Directed)

BIS and BAS

BIS BAS

Behavior (e.g., Withdraw, “Stop, look, & Listen”)

Behavior (e.g., Approach, Goal-Directed)

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BIS and BAS

BIS BASCognitive Content (e.g., Hurt ≠

Harm, Anticipate reward)

Emotion and affect (e.g., Excitement)

Behavior (e.g., Withdraw, “Stop, look, & Listen”)

Behavior (e.g., Approach, Goal-Directed)

Cognitive processes (e.g., Acceptance, Cognitive flexibility)

BIS and BAS

BIS BASCognitive Content (e.g., Pain = Danger, Anticipate punishment)

Cognitive Content (e.g., Hurt ≠ Harm, Anticipate reward)

Emotion and affect (e.g., Anxiety)

Emotion and affect (e.g., Excitement)

Behavior (e.g., Withdraw, “Stop, look, & Listen”)

Behavior (e.g., Approach, Goal-Directed)

Cognitive processes (e.g., Rumination, Hypervigilance)

Cognitive processes (e.g., Acceptance, Cognitive flexibility)

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BIS and BAS

BIS BASCognitive Content (e.g., Pain = Danger, Anticipate punishment)

Cognitive Content (e.g., Hurt ≠ Harm, Anticipate reward)

Emotion and affect (e.g., Anxiety)

Emotion and affect (e.g., Excitement)

Behavior (e.g., Withdraw, “Stop, look, & Listen”)

Behavior (e.g., Approach, Goal-Directed)

Cognitive processes (e.g., Rumination, Hypervigilance)

Cognitive processes (e.g., Acceptance, Cognitive flexibility)

(-)

BIS and BAS

PainPerception

BIS BASCognitive Content (e.g., Pain = Danger, Anticipate punishment)

Cognitive Content (e.g., Hurt ≠ Harm, Anticipate reward)

Emotion and affect (e.g., Anxiety)

Emotion and affect (e.g., Excitement)

Behavior (e.g., Withdraw, “Stop, look, & Listen”)

Behavior (e.g., Approach, Goal-Directed)

Cognitive processes (e.g., Rumination, Hypervigilance)

Cognitive processes (e.g., Acceptance, Cognitive flexibility)

(+)

(-)

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BIS and BAS

PainPerception

BIS BASCognitive Content (e.g., Pain = Danger, Anticipate punishment)

Cognitive Content (e.g., Hurt ≠ Harm, Anticipate reward)

Emotion and affect (e.g., Anxiety)

Emotion and affect (e.g., Excitement)

Behavior (e.g., Withdraw, “Stop, look, & Listen”)

Behavior (e.g., Approach, Goal-Directed)

Cognitive processes (e.g., Rumination, Hypervigilance)

Cognitive processes (e.g., Acceptance, Cognitive flexibility)

(-)(+)

(-)

Key features

Automaticity

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Key features

Automaticity∆ via associative learning, not logic

Automaticity

BIS and BAS reponses are automatic – you cannot easily stop them.

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Example 1

Example 1

VOMIT

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Example 1

We all had emotional, behavioral, and cognitive responses….

Example 1

We all had emotional, behavioral, and cognitive responses….

That were automatic

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Which system?

BIS BAS

Which system?

BIS

Emotion and affect

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Which system?

BIS

Emotion and affect

Behavior

Which system?

BISCognitive Content

Emotion and affect

Behavior

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Example 2

Example 2

Read the following

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Example 2

Read the following

Example 2

Now read the following

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Example 2

Example 2

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Example 2

Context (cues) influence our responses

Example 2

Context (cues) influence the response

Their influence is automatic

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Example 3

Example 3

What is the color of fresh fallen snow?

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Example 3

What is the color of fluffy (not rain) clouds?

Example 3

What is the color of a fresh sheet of standard Xerox paper?

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Example 3

What do cows drink?

Example 3

Context (cues) influence our responses

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Example 3

Context (cues) influence our responses

Their influence is automatic

Example 4

How many of each species …?

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Example 4

How many of each species …did Moses put on the ark?

Example 4

How many of each species …did Moses put on the ark?

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Example 4

Context (cues) influence our responses

Example 4

Context (cues) influence our responses

Their influence is automatic

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The characteristics of automaticity and mutual activation among networks may explain the effects of “seeding”

Example 5Bargh, J.A., Chen, M., & Burros, L. (1996). Automaticity of social behavior: Direct effects of

trait construct and sterotype activation on action. Journal of Personality and Social Psychology, 71, 230-244.

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Example 5Bargh, J.A., Chen, M., & Burros, L. (1996). Automaticity of social behavior: Direct effects of

trait construct and sterotype activation on action. Journal of Personality and Social Psychology, 71, 230-244.

Group 1: Make 4-word sentences from 30 short word lists, like…

ball the throw toss silentlyfrom are Florida oranges temperaturehe observes occasionally people watchessky the seamless grey isate she it selfishly allus bingo sing play let

Example 5Bargh, J.A., Chen, M., & Burros, L. (1996). Automaticity of social behavior: Direct effects of

trait construct and sterotype activation on action. Journal of Personality and Social Psychology, 71, 230-244.

Group 1: Make 4-word sentences from 30 short word lists, like…

ball the throw toss silently (e.g., Throw the ball silently)from are Florida oranges temperaturehe observes occasionally people watchessky the seamless grey isate she it selfishly allus bingo sing play let

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Example 5Bargh, J.A., Chen, M., & Burros, L. (1996). Automaticity of social behavior: Direct effects of

trait construct and sterotype activation on action. Journal of Personality and Social Psychology, 71, 230-244.

Group 2: A different list, such as …

flew eagle the plane aroundthe push wash frequently clothesthey obedient him often meetsend I will mail it you flowers the enjoy viewcat ran dog fast the

Example 5Bargh, J.A., Chen, M., & Burros, L. (1996). Automaticity of social behavior: Direct effects of

trait construct and sterotype activation on action. Journal of Personality and Social Psychology, 71, 230-244.

Outcome variable:The time it took participants to walk down a hallway after the conclusion of the experiment

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Example 5

Example 5

Group 1 list

ball the throw toss silentlyfrom are Florida oranges temperaturehe observes occasionally people watchessky the seamless grey isate she it selfishly allus bingo sing play let

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Example 5

Group 1 list

ball the throw toss silentlyfrom are Florida oranges temperaturehe observes occasionally people watchessky the seamless grey isate she it selfishly allus bingo sing play let

The characteristics of automaticity and mutual activation among networks may also explain the very large impact of HYP-CT on pain intensity

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BIS and BAS

PainPerception

BIS BASCognitive Content (e.g., Pain = Danger, Anticipate punishment)

Cognitive Content (e.g., Hurt ≠ Harm, Anticipate reward)

Emotion and affect (e.g., Anxiety)

Emotion and affect (e.g., Excitement)

Behavior (e.g., Withdraw, “Stop, look, & Listen”)

Behavior (e.g., Approach, Goal-Directed)

Cognitive processes (e.g., Rumination, Hypervigilance)

Cognitive processes (e.g., Acceptance, Cognitive flexibility)

(-)(+)

(-)

BIS and BAS

PainPerception

BIS BASCognitive Content (e.g., Pain = Danger, Anticipate punishment)

Cognitive Content (e.g., Hurt ≠ Harm, Anticipate reward)

Emotion and affect (e.g., Anxiety)

Emotion and affect (e.g., Excitement)

Behavior (e.g., Withdraw, “Stop, look, & Listen”)

Behavior (e.g., Approach, Goal-Directed)

Cognitive processes (e.g., Rumination, Hypervigilance)

Cognitive processes (e.g., Acceptance, Cognitive flexibility)

(-)(+)

(-)

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Hypnosis enhances efficacy of CBT

Kirsch, Montgomery, & Sapirstein, 1995- Meta-analysis of 18 studies comparing CBT

vs. CBT supplemented by hypnosis- Pain, insomnia, hypertension, obesity,

phobia/anxiety, duodenal ulcer- Adding hypnosis substantially enhanced

treatment outcome; CBT+HYP > 70% receiving CBT alone. Perhaps adding hypnosis to CT will might

enhance ability benefits of CT?

Hypnosis enhances CT

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Average Pain Intensity

Pre Post

.04

.23

.56

.97

*

*

*

Hypnosis enhances CT

Pain Interference

Pre Post

-.03

.11

.16

.46

*

Hypnosis enhances CT

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Catastrophizing

Pre PostPost

.19

.27

.45

.61

*

Hypnosis enhances CT

What’s wrong w/ HYP Pain reduction?

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What’s wrong w/ HYP Pain reduction?

It focuses on….

What’s wrong with pain-focused HYP?

It focuses on….pain

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What’s wrong with pain-focused HYP?

It focuses on….pain

Image courtesy of FreeDigitalPhotos.net

What’s wrong with pain-focused HYP?

It focuses on….pain

Image courtesy of FreeDigitalPhotos.net

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What’s wrong with pain-focused HYP?

It focuses on….pain

Image courtesy of FreeDigitalPhotos.net

What’s wrong with pain-focused HYP?

It focuses on….pain

Image courtesy of FreeDigitalPhotos.net

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Which system does “pain” activate?

BIS BASCognitive Content (e.g., Pain = Danger, Anticipate punishment)

Cognitive Content (e.g., Hurt ≠ Harm, Anticipate reward)

Emotion and affect (e.g., Anxiety)

Emotion and affect (e.g., Excitement)

Behavior (e.g., Withdraw, “Stop, look, & Listen”)

Behavior (e.g., Approach, Goal-Directed)

Cognitive processes (e.g., Rumination, Hypervigilance)

Cognitive processes (e.g., Acceptance, Cognitive flexibility)

(-)(+)

(-)

Pain

Which system does “pain” activate?

BIS BASCognitive Content (e.g., Pain = Danger, Anticipate punishment)

Cognitive Content (e.g., Hurt ≠ Harm, Anticipate reward)

Emotion and affect (e.g., Anxiety)

Emotion and affect (e.g., Excitement)

Behavior (e.g., Withdraw, “Stop, look, & Listen”)

Behavior (e.g., Approach, Goal-Directed)

Cognitive processes (e.g., Rumination, Hypervigilance)

Cognitive processes (e.g., Acceptance, Cognitive flexibility)

(-)(+)

(-)

Pain

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Which system does “pain” activate?Which system does “pain” inhibit?

BIS BASCognitive Content (e.g., Pain = Danger, Anticipate punishment)

Cognitive Content (e.g., Hurt ≠ Harm, Anticipate reward)

Emotion and affect (e.g., Anxiety)

Emotion and affect (e.g., Excitement)

Behavior (e.g., Withdraw, “Stop, look, & Listen”)

Behavior (e.g., Approach, Goal-Directed)

Cognitive processes (e.g., Rumination, Hypervigilance)

Cognitive processes (e.g., Acceptance, Cognitive flexibility)

(-)(+)

(-)

Pain

Which system does “pain” activate?Which system does “pain” inhibit?

BIS BASCognitive Content (e.g., Pain = Danger, Anticipate punishment)

Cognitive Content (e.g., Hurt ≠ Harm, Anticipate reward)

Emotion and affect (e.g., Anxiety)

Emotion and affect (e.g., Excitement)

Behavior (e.g., Withdraw, “Stop, look, & Listen”)

Behavior (e.g., Approach, Goal-Directed)

Cognitive processes (e.g., Rumination, Hypervigilance)

Cognitive processes (e.g., Acceptance, Cognitive flexibility)

(-)(+)

(-)

Pain

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What’s right with HYP-CT?

It focuses on….

What’s right with HYP-CT?

It focuses on….Life

Images courtesy of FreeDigitalPhotos.net

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What’s right with HYP-CT?

It focuses on….Life

Images courtesy of FreeDigitalPhotos.net

What’s right with HYP-CT?

It focuses on….Life

Images courtesy of FreeDigitalPhotos.net

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What’s right with HYP-CT?

It focuses on….Life

Images courtesy of FreeDigitalPhotos.net

What’s right with HYP-CT?

It focuses on….Life

Images courtesy of FreeDigitalPhotos.net

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Which system does “joy” activate?

BIS BASCognitive Content (e.g., Pain = Danger, Anticipate punishment)

Cognitive Content (e.g., Hurt ≠ Harm, Anticipate reward)

Emotion and affect (e.g., Anxiety)

Emotion and affect (e.g., Excitement)

Behavior (e.g., Withdraw, “Stop, look, & Listen”)

Behavior (e.g., Approach, Goal-Directed)

Cognitive processes (e.g., Rumination, Hypervigilance)

Cognitive processes (e.g., Acceptance, Cognitive flexibility)

(+)

(-)

Joy

Which system does “joy” activate?

BIS BASCognitive Content (e.g., Pain = Danger, Anticipate punishment)

Cognitive Content (e.g., Hurt ≠ Harm, Anticipate reward)

Emotion and affect (e.g., Anxiety)

Emotion and affect (e.g., Excitement)

Behavior (e.g., Withdraw, “Stop, look, & Listen”)

Behavior (e.g., Approach, Goal-Directed)

Cognitive processes (e.g., Rumination, Hypervigilance)

Cognitive processes (e.g., Acceptance, Cognitive flexibility)

(+)

(-)

Joy

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Which system does “pain” activate?Which system does “joy” inhibit?

BIS BASCognitive Content (e.g., Pain = Danger, Anticipate punishment)

Cognitive Content (e.g., Hurt ≠ Harm, Anticipate reward)

Emotion and affect (e.g., Anxiety)

Emotion and affect (e.g., Excitement)

Behavior (e.g., Withdraw, “Stop, look, & Listen”)

Behavior (e.g., Approach, Goal-Directed)

Cognitive processes (e.g., Rumination, Hypervigilance)

Cognitive processes (e.g., Acceptance, Cognitive flexibility)

(+)(-)

(-)

Joy

Which system does “pain” activate?Which system does “joy” inhibit?

BIS BASCognitive Content (e.g., Pain = Danger, Anticipate punishment)

Cognitive Content (e.g., Hurt ≠ Harm, Anticipate reward)

Emotion and affect (e.g., Anxiety)

Emotion and affect (e.g., Excitement)

Behavior (e.g., Withdraw, “Stop, look, & Listen”)

Behavior (e.g., Approach, Goal-Directed)

Cognitive processes (e.g., Rumination, Hypervigilance)

Cognitive processes (e.g., Acceptance, Cognitive flexibility)

(+)(-)

(-)

Joy

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A treatment that does this…

Images courtesy of FreeDigitalPhotos.net

Results in this

Pain

BIS

BAS

Cognitive Content (e.g., Pain = Danger, Anticipate punishment)

Cognitive Content (e.g., Hurt ≠ Harm, Anticipate reward)

Emotion and affect (e.g., Anxiety)

Emotion and affect (e.g., Excitement)

Behavior (e.g., Withdraw, “Stop, look, & Listen”)

Behavior (e.g., Approach, Goal-Directed)

Cognitive processes (e.g., Rumination, Hypervigilance)

Cognitive processes (e.g., Acceptance, Cognitive flexibility)

(-)(+)

(-)

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Impact of thought change

Changing thoughts …- Has been shown to reduce depression in

individuals who are depressed (Jakobsen et al., 2011; Rupke et al., 2006)

- Has been shown to reduce pain intensity in individuals with chronic pain (Ehde & Jensen, 2004; Jensen et al., 2011))

Remember…

BIS and BAS reponses are automatic – you cannot easily stop them.

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So…

Changing activity within the BIS-BAS systems will have automatic effects on pain

Hypnosis…

- Changes what is activated and inhibited within the automatic response (BIS-BAS) systems

- Can make changes quickly- Can create responses that are

automatic (seem effortless)

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Hypnotic cognitive therapy

So we are looking to identify useful thoughts

And then make them automatic

Hypnotic cognitive therapy

Open questions and reflections to identify and “test drive” thoughts as suggestions

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Hypnotic cognitive therapy

Open questions and reflections to identify and “test drive” thoughts as suggestions

Hypnotic cognitive therapy

Open questions and reflections to identify and “test drive” thoughts as suggestions

Negotiate which suggestions the client finds most useful

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Hypnotic cognitive therapy

Open questions and reflections to identify and “test drive” thoughts as suggestions

Negotiate which suggestions the client finds most useful

Provide those suggestions with in a more formal hypnosis session

Using Open Qs and Reflection to Identify ATs

Open questions to elicit adaptive thoughts (effective hypnotic suggestions) about pain

Reflective listening (restate and “test drive” suggestions)

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Adaptive Thoughts (often, BAS)

Self-efficacy (I can…)Importance (I would like…)Affirmations (I am…)Optimism/Hope (It will…)Flexibility (Either way…)Intent (I will….)

I can…

I can’tI will…

I will never…

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Open Qs to identify content

I can…

I can’tI will…

I will never…

Reflection to enhance & “test drive” suggestions

I can…I can’t

I will…I will never…

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Hypnosis to enhance suggestions

I can…I can’t

I will…I will never…

Open Questions

Open questions are ones that cannot be answered with a “yes’ or “no”

Open questions do not elicit specific answers like name or date.

Open questions get the client talking, hopefully about change

Using open questions you can demonstrate empathy and acceptance, and elicit ATs (potential suggestions)

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Converting Closed to Open Questions

Did you exercise much last week?

Do you do get to the gym three days a week?

Are you feeling better?

Are you willing to improve your diet?

Did you call the trainer I recommended?

Reflective Listening

Reflective listening involves being interested in what the person has to say and respect for the person’s inner wisdom.

Key element is hypothesis testing. A reflective statement tests a hypothesis: Is this what you mean?

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Reflective ListeningImportantly…- Reflections can be used to nurture

connections that already exist.- Can use reflections as to plant seeds for

new connections.- Reflections can be viewed as suggestions;

self-, “non-hypnotic”, and a source for formal hypnotic suggestions.

Forming Reflections

An effective reflective listening response is a statement, not a question. With questions inflection goes up at the end. With statements, inflection stays down at the end.

Example:- You’re angry about what I said?- You’re angry about what I said.

What is the effect of questions versus statements?

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Forming reflections1. Repeating (repeat an element).2. Rephrasing (repeat with synonyms).3. Paraphrase (repeat best guess at meaning; like

saying the next sentence instead of repeating the last one).

4. Reflection of feeling (paraphrase that emphasizes the emotional dimension).

Reflections are “truisms” as far as the client is concerned. They build rapport and a “yes” set, and yield useful suggestion content.

Reflective listening: Tips

Reflective listening (positive suggestion) stems:“So, you think…”“Your are wondering if…”“It sounds like …”“It must feel…”

Non-reflections:AdviceQuestioningWarning

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Hypnotic cognitive therapy

Open questions/reflections to identify and “test drive” thoughts as suggestions

Negotiate which suggestions the client finds most useful

Provide those suggestions with in a more formal hypnosis session

Demonstration 1

A volunteer interested in feeling better – less pain (more comfortable), more energy, more confident, happier….

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Demonstration 1

Therapist’s role: Listen for, note and “test drive” the ideas that are already inside the client that might make good suggestions – ideas and thoughts that you would want to nurture

Open questions/reflections to identify and “test drive” thoughts as suggestions

Demonstration 1

Open questions/reflections to identify and “test drive” thoughts as suggestions

Negotiate which suggestions the client finds most useful

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Demonstration 1

Open questions/reflections to identify and “test drive” thoughts as suggestions

Negotiate which suggestions the client finds most useful

Provide those suggestions with in a more formal hypnosis session

Demonstration 2

Therapist’s role: Listen for, note and “test drive” the ideas that are already inside the client that might make good suggestions – ideas and thoughts that you would want to nurture

Open questions/reflections to identify and “test drive” thoughts as suggestions

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Demonstration 2

Open questions/reflections to identify and “test drive” thoughts as suggestions

Negotiate which suggestions the client finds most useful

Demonstration 2

Open questions/reflections to identify and “test drive” thoughts as suggestions

Negotiate which suggestions the client finds most useful

Provide those suggestions with in a more formal hypnosis session

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Questions,Comments,

And Discussion

Thank you!

Images courtesy of stockimages at FreeDigitalPhotos.net