O'Grady Psychology Associates

Psychotherapy, Marriage Counseling, Neuropsychological Assessment

By 4 Comments

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.

 

By 4 Comments

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

By Leave a Comment

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

By Leave a Comment

Writing About Our Work: Psychologists as Writers

Writing About Our Work: Psychologists as Writers

The summer solstice has come and gone.  I hope that the long warm evenings are calling you to outside and you are able to find time to enjoy the summer we thought would never arrive.

In early June we hosted our continuing education program with a salon-style meeting at my home.  The presentation, “Authors in Conversation: Publishing in Psychology,” attracted members who have an interest in writing.  In contrast to our usual extravagant Lafayette Park Hotel venue, we thought the intimate and informal home environment might foster a greater sense of community as well as a more discussion-based space for information sharing.   Our panel members included authors Drs. Andy Pojman, Rhoda Olkin, Ed Abramson, and Ann Steiner. We had the opportunity to ask these experienced writers about the fragile balance of maintaining a healthy psychotherapy practice and making time to write.

Their personal accounts and ideas, peppered with witty anecdotes, proved to be informative and fun.   There were many funny stories about all the creative ways to avoid sitting down to write.

The majority of psychologists practice in isolation.  At the heart of psychotherapy is confidentiality.  Rich with poignancy and vivid in pathos, we have profound and even sacred moments that are worthy of re-telling.  However, we go home at the end of a day and are bound by our code of ethics to not talk about what we do.

I have often been with friends who ask how my day was, and I smile and say “it was a good day, or it was a full day”, or another equally vague response.   Early in my career, I would have to monitor myself at book groups and dinner parties to not begin a conversation with, “I had this patient who…” As psychologists, we are thus unable to contribute much of what we do during our workday, despite the often interesting and touching moments that make up our working life.

Yet we can write about our work.  All psychologists have experience in writing.  To become a psychologist we had to write a dissertation.  It is one of the things we did that separates us from other mental health professionals.  We may have agonized over the dissertation, and then once completed, we quickly moved onto the “real work” of helping our patients.

Building a full-time practice left little time for writing.  Yet as our authors described, making the time to put into words what we do allows us to develop as a professional and to contribute our expertise to our peers and the public.

President’s Message:  Published in the Contra Costa Psychological Association Newsletter July 2011