O'Grady Psychology Associates

Psychotherapy, Marriage Counseling, Neuropsychological Assessment

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Chronic Pain and Narcotics

A Behavioral Approach to Treating Chronic Pain and Medical Problems

In the June 2 edition of The New York Times, the article “Pain Pills Add Cost and Delays to Job Injuries” Barry Meier points out that powerful drugs such as OxyContin actually delay recovery from injuries that occur at work. But beyond the financial cost of using opioid painkillers to treat back strain and other pain problems, the human costs are heartbreaking.

I have treated chronic pain since I first began working as a psychotherapist. Using biofeedback, cognitive therapy, and relaxation training, I worked with medical patients referred by their physicians. The people I treated were on multiple medications from many different classifications within pharmacology. Sedatives were combined with opioids, sleeping pills, antidepressants, and mood stabilizers.

In the pre-digital age, where medical records were in the form of a paper chart, these patients had the thickest charts, often in several volumes. Pain patients can be docile, following doctor’s orders to take the pills exactly as prescribed. But in chronic pain, the tolerance to these strong medications grows. Increasing the drugs’ strength and frequency may not cure or even lessen pain; in fact, the pain is often made worse. In medical jargon, the pain becomes iatrogenic—meaning that the treatment causes the problem.

Over time, the side effects of taking opioids lead to a plethora of new medical and psychological problems. These drugs cause lethargy, drowsiness, depression, and irritability. The lifestyle behaviors that would ameliorate pain, such as exercise, relationships, and engagement in pleasurable activities, are difficult to do if one is bedridden due to stupor, further delaying recovery.

The cost to the patient’s family is also a big problem. The reduced income stresses everyone and reduces the patient’s self-esteem. The healthy partner becomes a caregiver, putting a strain on sex and intimacy. Pain patients take on what I call “pain behaviors” such as wincing, grimacing, and grunting, signals that often look like helpless dependency. Caregivers’ own helplessness to do anything, creates burnout, leading them to ignore patients’ suffering. Resentment grows on all sides. Marriage counseling is often warranted to help partners adapt to their spouses’ pain and to learn new ways of coping.

When I started treating chronic pain, Behavioral Intervention was the treatment model. Self-care was the cornerstone of healing, with medications as an adjunct. My work was to help patients see that being in bed most of the day and night was robbing them of their life. By suggesting and encouraging gradual exercise and teaching meditation and relaxation, I could help them begin to engage in life again. While working at Kaiser Hospital, I conducted research for my doctoral dissertation that showed a significant reduction in medical costs for patients who had completed short-term behavioral therapy for their chronic pain. The treatment was effective for reducing medical costs for up to five years after the therapy was concluded.

In addition to medical costs, the psychological literature has focused on the “secondary gain” of chronic pain. This refers to the usually unconscious benefits one derives from pain. This could come from worker’s compensation benefits, attention from family, or legal compensation from an injury incurred at work or an accident, but also the insidious creep of opioid dependence.

Chronic pain patients often fall through the cracks of the medical and legal system. Lawyers get involved. Settlements get delayed due to the difficulty getting appointments with doctors, medical examiners, and the many ancillary people involved in the care of these folks. This added complexity prolongs recovery thereby increasing the toll of chronic pain on the patient’s life.

A unified team approach is necessary to prevent this kind of delay. Delays cost in big ways. As the Times article states, insurers spend $1.4 billion a year on narcotic painkillers. If these medications are used too early, too frequently, or for too long, the disability payouts and expenses will end up delaying return to work and in many cases will lead to permanent disability. In 2010, prescribed opioids cost $252 million in California. This cost is passed onto the taxpayers, who underwrite coverage for public employees like firefighters and police officers.

In this time of budget cuts, and controversy regarding pension plans we need to work in a systematic way to help the patient learn to cope with pain without the use of addictive medications. This will alleviate the burden on many fronts. Psychologists have had a role in treating patients with medical conditions for many years, yet referrals for mental health treatment have been affected because of to the many restrictions insurance companies put on providers, and limited coverage for this form of treatment.

One of the most effective treatment approaches is Mindfulness-Based Cognitive Therapy and Stress Reduction. This approach often utilizes a group format so that coping techniques can be taught efficiently. A growing body of research supports the use of meditation, and acceptance, in the treatment of medical problems. Psychologists can diagnose other problems a patient may be experiencing such as depression and anxiety, that may be compounding recovery. I often make recommendations for couples therapy. A comprehensive team approach is the most effective way to help a patient recover so that use of addictive medications will not impede a return to living life well, despite recurrent medical problems.

 

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Appreciating the Absence of Pain

 

You don’t appreciate not having a toothache until you have a toothache.  Sitting in the endodontist’s chair last week, I was asked if my tooth ached.  I paused for a long moment, and then replied, “ache is a very vague term”.  We both laughed.  Pain is difficult to measure.  Equally difficult to measure is joy– elusive and fleeting.

Thich Nhat Hanh used the toothache analogy when he spoke to a group of therapists many years ago. “When you have a toothache, you are enlightened—you know something very important—that not having a toothache is a wonderful thing. “

He further elaborated; “when you do not have a toothache, you don’t seem to enjoy it—peace is there in the present moment, but we find it boring and that is why we look for something more exciting”.   It feels so good when a toothache finally goes away.  If only we could appreciate the absence of that pain all the time.

Not all pain can be resolved by a dental procedure.  We are surrounded by pain in our work.  We see so many varieties of suffering, some themes repeated like a familiar chorus, others particular and unique to a single human being.   Our hearts ache with the daily news from places both remote and in our own backyards.  But when we experience extraordinary pain, we remember how fortunate we were for the time when pain was absent. Most of the time, however, we slug through our days, not noticing the absence of pain.

During the root canal, I listened to a favorite playlist on my iPod.  Steve Jobs had died a few days before.  I could not help but silently thank him for the music that distracted and entertained me, drowning out the sound of the drill.  Like many, I shed tears when I heard the news of the great man’s death. Grief is too strong a word for my feelings.  Rather, I felt a tender softness for the man I never met, for he enhanced my life at almost every turn.  From the podcasts that enrich me, to the MacAirbook that keeps track of my notes and projects, power points and photos, to the iPad that keeps me from double booking my clients (most of the time) and gives me a library full of books, and finally to that most magical of devices, my iPhone—that lets me check the weather, the news, the map, and gives me countless sources of entertainment.

Technology has enhanced our lives.   We have become experts at multitasking.  But it is in the moments of quiet, when our senses are awake, that we can feel the absence of ache.

Autumn has arrived.  October is my favorite month.  It is the month of my birth, but that is not the main reason I love it.  I love the long shadows and the harvest moon.  The light and the darkness meld into one another as the center of day holds until it succumbs and leaves the evenings long, for soup, for hearth, for stories.

And with the arrival of autumn, the holiday season approaches.  Our clients feel the tug of opposing emotions—joy, gratitude, resentment, and disappointment. We listen.   And we try to help integrate their dark and light.

But at the end of the day, we must shed our helping selves for a time, so that we can appreciate the absence of ache.  So that we can enjoy the moments that, when strung together, give us that delicious taste of all that is good in our lives.

“Be hungry, be foolish.”  Mr. Jobs spoke that advice at Stanford after hearing of his cancer diagnosis.    As we head into this holiday season where autumn fades into winter, let’s remember to be hungry for creative urges, for love, and for all that feeds us around the hearth. In our consulting rooms as we listen deeply to our clients as they work with their pain let us be present.

I remind myself to be playful and look for newness even if it seems foolish.  Mindful living is to be in touch with life—in order to enjoy the presence of your non- toothache.

Originally published:  President’s Column October 21, 2011

 

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Empty Nest, Work-Life Balance, and Political Action

Anticipating an empty nest, I decided to join the Contra Costa Psychological Association’s Board of Directors.  My twin daughters were in their final year of high school, and instead of the anxiety that usually comes with that impending transition (or perhaps because of it), I decided to get more involved in my profession.  Years ago, my husband and business partner Dr. David O’Grady, was president of the CCPA board.  During those days when our daughters were young, I felt the usual work-life balance conflict that consumes so many working mothers.  I would find myself questioning David’s decision to devote the little free time he had to the Contra Costa Psychological Association.  For me, I was either seeing as many clients as I could during the day, or I was at home, making up for the time I devoted to working. Because we were both in private practice, we were fortunate to be able to set our own schedules, so childcare was minimized.  Nonetheless, it was still completely unfathomable to me that David would choose to give away his time, especially to the profession.  After years of graduate school, internships and fellowships (e.g., working for free, or almost free), it was inconceivable to me that anyone would give yet more time to the profession that had taken so much from us already.

 Don’t get me wrong, I love my work and always have. But I also loved being a mother and it was important to me to balance these roles.  I could imagine giving time to other causes, such as preserving the Open Space or helping in my daughter’s classroom but could not imagine giving any more time to psychology.

Several years ago psychologists were writing about the concept of “Lost and Found Possible Selves”.  This construct represents the idea that in living life, we make choices and those choices mean that we give up certain possible selves.  For me to be a mother and a psychologist meant that I had to give up certain aspirations, such as owning a horse.  I also gave up the dream of being a yoga teacher (more on that to come).  So, in recent years I began to see the empty nest as an opening and realized that I desired more affiliation.  I had the time to give back to the profession.

Research on Lost Possible Selves suggests that confronting lost goals, or lost possible selves, can be a portent of personality development in later life.  With my daughters now happily engaged in their second year of college, I am reaching beyond old goals to build new connections and to new work on the board of CCPA.

 These new connections reach to Sacramento.  At CPA’s Leadership and Advocacy Conference, I was impressed by the vitality of our legislative process.  It is an annual three-day event that includes two days of focused leadership and advocacy training and one day devoted to face-to-face advocacy with legislators on current bills relevant to psychology. I saw first-hand decision-making in action and along with Dr. Howard Friedman, was able to play an active role.  Fifty psychologists and graduate students attended the training, and we added another fifty-two on Tuesday when we made our visits to the legislators’ offices in the capitol.  Two graduate students, Kristin Moore and Roxanne Untal from our county, joined Dr. Friedman and me in meetings with Senator Mark DeSaulnier, Assembly Member Joan Buchanan, and Assembly Member Susan Bonilla.

We discussed AB 154, the Mental Health Parity Bill.  This state version of the Federal Parity law would implement full mental health parity improving upon the existing state law.   Our legislators were attentive and approachable, and they took a keen interest in the concerns we raised.  What impressed me the most was that each engaged us in thoughtful dialogue about key issues facing the Contra Costa community.  It was clear to me that our representatives are well informed and aware of the psychological issues facing their constituents.

Senator DeSaulnier expressed concern about the “revolving door,” specifically in regards to mental health within the correctional system. He also voiced concern about children’s mental health and the need to create change at the family, school, and community levels. He was very interested in attending a meet-and-greet to gain a better understanding of the issues facing psychologists, and voiced interest in the prospect of future collaboration with members of CCPA.

Assembly Member Susan Bonilla specifically was concerned about mental health issues.  When she was a County Supervisor, she advocated for health care reform. She understands the impact of the loss of AB 3632 funds (for school mental health services), but recognizes it as an opportunity to reform the system. She is interested in the development of written guidelines that better delineate how insurance companies differentiate “behavioral” and “medical” treatment.  She asked how much it would cost insurance companies if they were to cover additional diagnoses.  She was interested in psychological services on school campuses as well as who should be held financially responsible for these services. Assemblywoman Bonilla is also interested in a meet-and-greet to learn more about the challenges currently faced by psychologists.

To our delight, the senate health committee passed SB 105, the Helmet Bill the day after our visit, by a vote of 7-1.  The Mental Health Parity Bill will not be heard until later in the year.  If passed, it will make an enormous difference to our clients in that it would expand existing insurance coverage of the nine most severe diagnoses, to mandate coverage for treatment of diagnoses such as GAD, PTSD, delusional disorder, and cognitive disorders.  As psychologists, we know that if less severe problems are treated early in their course, they will not progress to chronic problems.

CPA and Political Action

There are 18,000 psychologists in the state of California.  CPA has only 4,000 active members.  Of those 4000 CPA members, only 150 have contributed to CPA’s Political Action Committee (PAC) a mere 1% of licensed psychologists in the state.  This is a shameful statistic.  We are a group of professionals who have a doctorate degree that represents many years of study, research, and training.  Yet of all health professionals, we contribute almost the least to political action.  MFTs’ contribute twice as much as psychologists.

By strengthening CPA, we strengthen the psychologist voice in the state.  There are many threats to our professional status, including erosion of licensing laws that distinguish us from other mental health professionals, budget cuts that could reduce reimbursement and shrink services to those who need it most.  The Political Action Committee needs your contribution.  Please get out your checkbook or go online http://www.cpapsych.org/displaycommon.cfm?an=15 to donate and learn more about CPA and Political Action.  Our licenses are in jeopardy.  The lines between psychologists and other mental health professionals are beginning to blur.  We need to support and mentor early career psychologists.  To this end, CCPA’s board is stepping up our efforts to invite graduate students to our organization. We will be creating a student representative position on the board of CCPA.  CPA already has an active CPAGS or California Psychological Association of Graduate Students.  The CPAGS leadership team communicates information relevant to students via their website www.psychgrads.com, their list serves, and social networking sites such as Face book and Twitter.

In February I finished my Yoga Teacher Training at the 200-hour level.  I am beginning to incorporate concepts of yoga therapy into my psychotherapy practice.  I am especially excited to begin teaching psychologists and other professions who sit all day, how to do yoga from a chair!

Originally published:  President’s Message  Contra Costa Psychological Association April 2011

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Psychotherapy and Change

I officially started my tenure as President of our association on January 1, but the gavel was passed at our annual meeting on January 21.  As I listened to John Preston, Ph.D. talk about Managing Resistances in Psychotherapy, I was reminded of the uniqueness [struck again by] of our profession.   He mentioned the incubation chambers of ancient times, when a person in emotional pain, turmoil, or grief would go into a darkened chamber with a Holy Person for three days.  The idea being that when one is in despair, healing comes by being with the feelings, and allowing the feelings to be present.  In our psychotherapy offices, we often re-create such a chamber, a container for those feelings to be expressed as we listen deeply.  When someone is suffering, the willingness to go into the dark with them as they express and move through their feelings is a large part of what we do as psychologists.

What do we do in our offices to help alleviate the pain our clients come to us with?  There is a plethora of wisdom that comes through the ages to guide us.  Rumi stated it well:

“Everything you see has its roots in the unseen world. The forms may change, yet the essence remains the same. Every wonderful sight will vanish; every sweet word will fade, But do not be disheartened, The source they come from is eternal, growing, branching out, giving new life and new joy. Why do you weep? The source is within you and this whole world is springing up from it.”
    
— Jelaluddin Rumi

And Carl Jung wrote:  “Your vision will become clear only when you can look into your own heart… Who looks outside, dream; who looks inside, awakes. 

In this time of evidence-based therapies, we are often pressured to keep our clients from experiencing painful emotions, by suggesting alternative cognitions, or practices that will alleviate their discontent.     We think about outcomes, often with an imaginary HMO adjuster sitting in the room as we work.  I have been fortunate over the years to have a practice that does not rely on insurance panels.  But it was not always that way.

When I left California Pacific Medical Center in San Francisco to start my private practice, I joined most insurance panel as a PPO provider.  That was over twenty years ago. Those were the days when PPO had just come into being, and they were good to us.  We were allowed to charge fees much higher than HMOs and Medicare, currently, allow psychologists to charge.  It was before managed care.  It was the time when psychologists fought for hospital admitting privileges, and to be allowed membership to Psychoanalytic Institutes.  Both of which we got only to find out that the times-were-a changing, and while we were able to admit patients to inpatient hospitals, we were to learn that we would collect little if any reimbursement.  I know because I did get admitting privileges at Walnut Creek Hospital.  And then the bottom fell out of the inpatient market.  Psychiatric hospitals were closing and many psychiatrists were leaving hospital-based practices as well.

Psychologists (with the aid of our professional organizations, The California Psychological Association and The American Psychological Association(CPA and APA) waged a battle to gain access to Psychoanalytic Institutes.  Just as we were granted admittance to these elite institutes, the demand for long-term psychoanalytic therapy was on the wane.  Once again, the timing was not with us.  Cognitive therapy had arrived on the scene with a wham.

There have been many other changes, exciting and innovative.  We have learned more about brain function with FMRI.  Our understanding of neurobiology is beginning to guide our work.  The evolving knowledge of the effects of techniques such as Mindfulness, EMDR, and evidence-based therapies such as DBT, MBCT, ACT and Emotionally Focused Therapy are pervasive in the culture.

These and other numerous developments make our profession an interesting and growing one.  I think about the direction our field is taking now, I see a limitless future. Many are working for less income that in previous years, but the possibilities for a fulfilling practice continue to grow.   As a profession, we will continue to use evidenced-based therapies, while we help our clients to ride the waves of their emotional lives, helping to bring them from darkness to light.

It is an honor to accept the responsibility of the position of President of this association.  In doing so, I become the newest link in a chain of psychologists who have served as president before me, psychologists who have generously given their time, energy and creativity to serve the membership of our organization.

We are a diverse membership.  Geographically, we span Contra Costa County from Antioch to Orinda, and from San Ramon to Martinez.  We represent a diverse economic area as well.  Our membership ranges in age from newly licensed psychologists to the many old-timers, the group to which I now belong.

Those of you who have been around that long – and you know who you are—will remember that Dr. Beth Hall created a website for our organization that displayed each member’s names, a photo, and a description of their practices.  Over the years, that evolved into an Information and Referral page, as the website was reconfigured.  The I & R became a marketing tool for its members as well as a resource for the public to get referrals to members on the I&R, and information regarding low fee clinics and other support organizations.

Originally published as:  President’s Message January 28, 2011

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Our Evolving Field

Our Evolving Field

For several years every spring I have spoken at Career Day at our local high school and middle school. Men and women representing many diverse jobs assemble in the multi-purpose room for coffee in the morning before being dispersed to the assigned classrooms to speak with high school students about our jobs. To my delight, on each occasion, the Psychologist profession had the largest turnout.

One of the most common questions asked is, “Why did you choose to become a psychologist?” I love this question. It challenges on many levels. Being careful to not discourage, I avoid the words HMO, managed care, reimbursement and collection problems. I also tread lightly when discussing the different degrees and licenses of those who work in mental health. I refrain from talking about unpaid internships and the cost of graduate school. Those in the room are clearly interested in our profession––they are learning about themselves, learning how they are like or unlike others, discovering the patterns that underlie the complexities of how we think and feel. I see in these kids the excitement that launched me, and others like me, into a career in psychology.

We are indeed a privileged profession. In each person who comes to us, there lies a story to be found. The story usually has a universal motif and a theme distinctive to that individual life. When I describe our work to students, I often use the image of having a stack of books on my table, and each hour I take down a different volume, open to a chapter that flows from the previous hour a week apart. Most men and women who come to us for therapy seek wholeness, and the stories that unfold bit by bit, hour by hour, nourish the thirst for, as Dante wrote, “the love that moves the sun and the other stars.”

Our field is rapidly changing with the addition of neurocognitive sciences, and changes in diagnostic criteria and treatment strategies for a number of disorders. Research is continually evolving and our access to information and databases is unparalleled. It is exciting to see the eagerness of high-school students, and graduate students as they explore the field of psychology.

The Contra Costa Psychological Association welcomes graduate students and early career psychologists to our organization. We have seasoned and accomplished members who are working on mentoring. Both the California Psychological Association and the American Psychological Association have made great efforts to help younger psychologists to find work. These organizations offer programs in mentorship, leadership, grant writing, and free legal and ethical hotlines. In addition, they provide tangible, value-added resources such as financial planning, debt reduction, and loan repayment. Resources such as these are immensely valuable at a time when job stability is tenuous.

Originally published: President’s Message Spring 2012