Acceptance and commitment therapy

From Wikipedia, the free encyclopedia

 

Acceptance and commitment therapy
MeSH	D064869

Acceptance and commitment therapy (ACT, typically pronounced as the word "act") is a form of counseling and a branch of clinical behavior analysis. It is an empirically-based psychological intervention that uses acceptance and mindfulness strategies mixed in different ways with commitment and behavior-change strategies, to increase psychological flexibility. The approach was originally called comprehensive distancing. Steven C. Hayes developed Acceptance and Commitment Therapy in 1982 in order to create a mixed approach which integrates both cognitive and behavioral therapy. There are a variety of protocols for ACT, depending on the target behavior or setting. For example, in behavioral health areas a brief version of ACT is called focused acceptance and commitment therapy (FACT).

The objective of ACT is not elimination of difficult feelings; rather, it is to be present with what life brings us and to "move toward valued behavior". Acceptance and commitment therapy invites people to open up to unpleasant feelings, and learn not to overreact to them, and not avoid situations where they are invoked. Its therapeutic effect is a positive spiral where feeling better leads to a better understanding of the truth. In ACT, 'truth' is measured through the concept of 'workability', or what works to take another step toward what matters (e.g. values, meaning).

Technique

Basics

ACT is developed within a pragmatic philosophy called functional contextualism. ACT is based on relational frame theory (RFT), a comprehensive theory of language and cognition that is an offshoot of behavior analysis. Both ACT and RFT are based on B. F. Skinner's philosophy of Radical Behaviorism.

ACT differs from traditional cognitive behavioral therapy (CBT) in that rather than trying to teach people to better control their thoughts, feelings, sensations, memories and other private events, ACT teaches them to "just notice," accept, and embrace their private events, especially previously unwanted ones. ACT helps the individual get in contact with a transcendent sense of self known as "self-as-context"—the you who is always there observing and experiencing and yet distinct from one's thoughts, feelings, sensations, and memories. ACT aims to help the individual clarify their personal values and to take action on them, bringing more vitality and meaning to their life in the process, increasing their psychological flexibility.

While Western psychology has typically operated under the "healthy normality" assumption which states that by their nature, humans are psychologically healthy, ACT assumes, rather, that psychological processes of a normal human mind are often destructive. The core conception of ACT is that psychological suffering is usually caused by experiential avoidance, cognitive entanglement, and resulting psychological rigidity that leads to a failure to take needed behavioral steps in accord with core values. As a simple way to summarize the model, ACT views the core of many problems to be due to the concepts represented in the acronym, FEAR:

Cards used as a therapeutic activity in ACT treatment.

• Fusion with your thoughts
• Evaluation of experience
• Avoidance of your experience
• Reason-giving for your behavior

And the healthy alternative is to ACT:

• Accept your reactions and be present
• Choose a valued direction
• Take action

Core principles

ACT commonly employs six core principles to help clients develop psychological flexibility:

1. Cognitive defusion: Learning methods to reduce the tendency to reify thoughts, images, emotions, and memories.
2. Acceptance: Allowing unwanted private experiences (thoughts, feelings and urges) to come and go without struggling with them.
3. Contact with the present moment: Awareness of the here and now, experienced with openness, interest, and receptiveness. (e.g., mindfulness)
4. The observing self: Accessing a transcendent sense of self, a continuity of consciousness which is unchanging.
5. Values: Discovering what is most important to oneself.
6. Committed action: Setting goals according to values and carrying them out responsibly, in the service of a meaningful life.

Correlational evidence has found that absence of psychological flexibility predicts many forms of psychopathology. A 2005 meta-analysis showed that the six ACT principles, on average, account for 16–29% of the variance in psychopathology (general mental health, depression, anxiety) at baseline, depending on the measure, using correlational methods. A 2012 meta-analysis of 68 laboratory-based studies on ACT components has also provided support for the link between psychological flexibility concepts and specific components.

Research

A 2008 meta-analysis concluded that the evidence was still too limited for ACT to be considered a supported treatment, and raised methodological concerns about the research base. A 2009 meta-analysis found that ACT was more effective than placebo and "treatment as usual" for most problems (with the exception of anxiety and depression), but not more effective than CBT and other traditional therapies. A 2012 meta-analysis was more positive and reported that ACT outperformed CBT, except for treating depression and anxiety.

A 2015 review found that ACT was better than placebo and typical treatment for anxiety disorders, depression, and addiction. Its effectiveness was similar to traditional treatments like cognitive behavioral therapy (CBT). The authors suggested that the CBT comparison of the previous 2012 meta-analysis may have been compromised by the inclusion of nonrandomized trials with small sample sizes. They also noted that research methodologies had improved since the studies described in the 2008 meta-analysis.

The number of randomized clinical trials and controlled time series evaluating ACT for a variety of problems is growing. In 2006, only about 30 such studies were known, but in 2011 the number had approximately doubled. The website of the Association for Contextual Behavioral Science states that there were 171 randomized controlled trials (RCTs) of ACT published as of December 2016, and over 20 meta-analyses and 45 mediational studies of the ACT literature as of Spring 2016. Most studies of ACT so far have been conducted on adults and therefore the knowledge of its effectiveness when applied to children and adolescents is limited.

Similarities

ACT, dialectical behavior therapy (DBT), functional analytic psychotherapy (FAP), mindfulness-based cognitive therapy (MBCT) and other acceptance- and mindfulness-based approaches are commonly grouped under the name "the third wave of cognitive behavior therapy". The first wave, behaviour therapy, commenced in the 1920s based on Pavlov's classical (respondent) conditioning and operant conditioning that was correlated to reinforcing consequences. The second wave emerged in the 1970s and included cognition in the form of irrational beliefs, dysfunctional attitudes or depressogenic attributions. In the late 1980s empirical limitations and philosophical misgivings of the second wave gave rise to Steven Hayes' ACT theory which modified the focus of abnormal behaviour away from the content or form towards the context in which it occurs. ACT research has suggested that many of the emotional defenses individuals use with conviction to try to solve their problems actually entangle humans into greater suffering. Rigid ideas about themselves, lack of focus on what is important in their life and struggling to change sensations, feelings or thoughts that are troublesome only serve to create greater distress.

Steven C. Hayes described this group in his ABCT President Address as follows:

Grounded in an empirical, principle-focused approach, the third wave of behavioral and cognitive therapy is particularly sensitive to the context and functions of psychological phenomena, not just their form, and thus tends to emphasize contextual and experiential change strategies in addition to more direct and didactic ones. These treatments tend to seek the construction of broad, flexible and effective repertoires over an eliminative approach to narrowly defined problems, and to emphasize the relevance of the issues they examine for clinicians as well as clients. The third wave reformulates and synthesizes previous generations of behavioral and cognitive therapy and carries them forward into questions, issues, and domains previously addressed primarily by other traditions, in hopes of improving both understanding and outcomes.

ACT has also been adapted to create a non-therapy version of the same processes called Acceptance and Commitment Training. This training process, oriented towards the development of mindfulness, acceptance, and valued skills in non-clinical settings such as businesses or schools, has also been investigated in a handful of research studies with good preliminary results. This is somewhat similar to the awareness–management movement in business training programs, where mindfulness and cognitive-shifting techniques are employed.

The emphasis of ACT on ongoing present moment awareness, valued directions and committed action is similar to other psycho-therapeutic approaches that, unlike ACT, are not as focused on outcome research or consciously linked to a basic behavioral science program, including approaches such as Gestalt therapy, Morita therapy and Voice Dialogue, IFS and others.

Wilson, Hayes & Byrd explore at length the compatibilities between ACT and the 12-step treatment of addictions and argue that, unlike most other psychotherapies, both approaches can be implicitly or explicitly integrated due to their broad commonalities. Both approaches endorse acceptance as an alternative to unproductive control. ACT emphasizes the hopelessness of relying on ineffectual strategies to control private experience, similarly the 12-step approach emphasizes the acceptance of powerlessness over addiction. Both approaches encourage a broad life-reorientation, rather than a narrow focus on the elimination of substance use, and both place great value on the long-term project of building of a meaningful life aligned with the clients' values. ACT and 12-step both encourage the pragmatic utility of cultivating a transcendent sense of self (higher power) within an unconventional, individualized spirituality. Finally they both openly accept the paradox that acceptance is a necessary condition for change and both encourage a playful awareness of the limitations of human thinking.

Criticisms

Some published empirical studies in clinical psychology have argued that ACT is not different from other interventions. Stefan Hofmann argued that ACT is similar to the much older Morita therapy.

A meta-analysis by Öst in 2008 concluded that ACT did not yet qualify as an "empirically supported treatment", that the research methodology for ACT was less stringent than cognitive behavioral therapy, and that the mean effect size was moderate. Supporters of ACT have challenged those conclusions by showing that the quality difference in Öst's review was accounted for by the larger number of funded trials in the CBT comparison group.

Several concerns, both theoretical and empirical, have arisen in response to the ascendancy of ACT. One major theoretical concern is that the primary authors of ACT and of the corresponding theories of human behavior, relational frame theory (RFT) and functional contextualism (FC), recommend their approach as the proverbial holy grail of psychological therapies. Psychologist James C. Coyne, in a discussion of "disappointments and embarrassments in the branding of psychotherapies as evidence supported", said: "Whether or not ACT is more efficacious than other therapies, as its proponents sometimes claim, or whether it is efficacious for psychosis, is debatable". The textbook Systems of Psychotherapy: A Transtheoretical Analysis provides criticisms of third-wave behaviour therapies including ACT from the perspectives of other systems of psychotherapy.

Psychologist Jonathan W. Kanter said that Hayes and colleagues "argue that empirical clinical psychology is hampered in its efforts to alleviate human suffering and present contextual behavioral science (CBS) to address the basic philosophical, theoretical and methodological shortcomings of the field. CBS represents a host of good ideas but at times the promise of CBS is obscured by excessive promotion of Acceptance and Commitment Therapy (ACT) and Relational Frame Theory (RFT) and demotion of earlier cognitive and behavior change techniques in the absence of clear logic and empirical support." Nevertheless, Kanter concluded that "the ideas of CBS, RFT, and ACT deserve serious consideration by the mainstream community and have great potential to shape a truly progressive clinical science to guide clinical practice."

ACT currently appears to be about as effective as standard CBT, with some meta-analyses showing small differences in favor of ACT and others not. For example, a meta-analysis published by Francisco Ruiz in 2012 looked at 16 studies comparing ACT to standard CBT. ACT failed to separate from CBT on effect sizes for anxiety, however modest benefits were found with ACT compare to CBT for anxiety and quality of life. The author did find separation between ACT and CBT on the "primary outcome" – a heterogeneous class of 14 separate outcome measures that were aggregated into the effect size analysis. This analysis however is limited by the highly heterogeneous nature of the outcome variables used in the analysis, which has the tendency to increase the number needed to treat (NNT) to replicate the effect size reported. More limited measures, such as depression, anxiety and quality of life decrease the NNT, making the analysis more clinically relevant, and on these measures ACT did not outperform CBT. 

A 2013 paper comparing ACT to cognitive therapy (CT) concluded that "like CT, ACT cannot yet make strong claims that its unique and theory-driven intervention components are active ingredients in its effects." The authors of the paper suggested that many of the assumptions of ACT and CT "are pre-analytical, and cannot be directly pitted against one another in experimental tests."

Professional organizations

The Association for Contextual Behavioral Science is committed to research and development in the area of ACT, RFT, and contextual behavioral science more generally. As of 2017 it had over 7,600 members worldwide, about half outside of the United States. It holds annual "world conference" meetings: The 16th will be held in Montreal, in July 2018.

The Association for Behavior Analysis International (ABAI) has a special interest group for practitioner issues, behavioral counseling, and clinical behavior analysis ABA:I. ABAI has larger special interest groups for autism and behavioral medicine. ABAI serves as the core intellectual home for behavior analysts. ABAI sponsors three conferences/year—one multi-track in the U.S., one specific to Autism and one international.

The Association for Behavioral and Cognitive Therapies (ABCT) also has an interest group in behavior analysis, which focuses on clinical behavior analysis. ACT work is commonly presented at ABCT and other mainstream CBT organizations. 

The British Association for Behavioural and Cognitive Psychotherapies (BABCP) has a large special interest group in ACT, with over 1,200 members. 

Doctoral-level behavior analysts who are psychologists belong to the American Psychological Association's (APA) Division 25—Behavior analysis. ACT has been called a "commonly used treatment with empirical support" within the APA-recognized specialty of behavioral and cognitive psychology.

Chronic pain

From Wikipedia, the free encyclopedia

 

Chronic pain
Specialty	Pain management

Chronic pain is pain that lasts a long time. In medicine, the distinction between acute and chronic pain is sometimes determined by an arbitrary interval of time since onset; the two most commonly used markers being 3 months and 6 months since onset, though some theorists and researchers have placed the transition from acute to chronic pain at 12 months. Others apply acute to pain that lasts less than 30 days, chronic to pain of more than six months duration, and subacute to pain that lasts from one to six months. A popular alternative definition of chronic pain, involving no arbitrarily fixed duration, is "pain that extends beyond the expected period of healing". Epidemiological studies have found that 10.1% to 55.2% of people in various countries have chronic pain.

Chronic pain may originate in the body, or in the brain or spinal cord. It is often difficult to treat. Various nonopioid medicines are recommended initially, depending on whether the pain originates from tissue damage or is neuropathic. Psychological treatments including cognitive behavioral therapy and acceptance and commitment therapy may be effective for improving quality of life in those with chronic pain. Some people with chronic pain may benefit from opioid treatment while others are harmed. In people with non-cancer pain, a trial of opioids is only recommended if there is no history of either mental illness or substance use disorder and should be stopped if not effective.

Severe chronic pain is associated with increased 10-year mortality, particularly from heart disease and respiratory disease. People with chronic pain tend to have higher rates of depression, anxiety, and sleep disturbances; these are correlations and it is often not clear which factor causes another. Chronic pain may contribute to decreased physical activity due to fear of exacerbating pain, often resulting in weight gain. Pain intensity, pain control, and resiliency to pain are influenced by different levels and types of social support that a person with chronic pain receives.

Classification

The International Association for the study of pain defines chronic pain as pain with no biological value, that persists past normal tissue healing. The DSM-5 recognizes one chronic pain disorder, somatic symptom disorders, a reduction from the three previously recognized pain disorders. The criteria include it lasting for greater than six months.

The suggested ICD-11 chronic pain classification suggests 7 categories for chronic pain.

1. Chronic primary pain: defined by 3 months of persistent pain in one or more anatomical regions that is unexplainable by another pain condition.
2. Chronic cancer pain: defined as cancer or treatment related visceral, musculoskeletal, or bony pain.
3. Chronic posttraumatic pain: pain lasting 3 months post trauma or surgery, excluding infectious or preexisting conditions.
4. Chronic neuropathic pain: pain caused by damage to the somatosensory nervous system.
5. Chronic headache and orofacial pain: pain that originates in the head or face, and occurs for 50% or more days over a 3 months period.
6. Chronic visceral pain: pain originating in an internal organ.
7. Chronic musculoskeletal pain: pain originating in the bones, muscles, joints or connective tissue.

Chronic pain may be divided into "nociceptive" (caused by inflamed or damaged tissue activating specialised pain sensors called nociceptors), and "neuropathic" (caused by damage to or malfunction of the nervous system).

Nociceptive pain may be divided into "superficial" and "deep", and deep pain into "deep somatic" and "visceral". Superficial pain is initiated by activation of nociceptors in the skin or superficial tissues. Deep somatic pain is initiated by stimulation of nociceptors in ligaments, tendons, bones, blood vessels, fasciae and muscles, and is dull, aching, poorly-localized pain. Visceral pain originates in the viscera (organs). Visceral pain may be well-localized, but often it is extremely difficult to locate, and several visceral regions produce "referred" pain when damaged or inflamed, where the sensation is located in an area distant from the site of pathology or injury.

Neuropathic pain is divided into "peripheral" (originating in the peripheral nervous system) and "central" (originating in the brain or spinal cord). Peripheral neuropathic pain is often described as "burning", "tingling", "electrical", "stabbing", or "pins and needles".

Causes

Pathophysiology

Under persistent activation nociceptive transmission to the dorsal horn may induce a pain wind-up phenomenon. This induces pathological changes that lower the threshold for pain signals to be transmitted. In addition it may generate nonnociceptive nerve fibers to respond to pain signals. Nonnociceptive nerve fibers may also be able to generate and transmit pain signals. The type of nerve fibers that are believed to propagate the pain signals are the C-fibers, since they have a slow conductivity and give rise to a painful sensation that persists over a long time. In chronic pain this process is difficult to reverse or eradicate once established. In some cases, chronic pain can be caused by genetic factors which interfere with neuronal differentiation, leading to a permanent reduction in the threshold for pain.

Chronic pain of different etiologies has been characterized as a disease affecting brain structure and function. Magnetic resonance imaging studies have shown abnormal anatomical and functional connectivity, even during rest involving areas related to the processing of pain. Also, persistent pain has been shown to cause grey matter loss, reversible once the pain has resolved.

These structural changes can be explained by the phenomenon known as neuroplasticity. In the case of chronic pain, the somatotopic representation of the body is inappropriately reorganized following peripheral and central sensitization. This maladaptive change results in the experience of allodynia or hyperalgesia. Brain activity in individuals with chronic pain, measured via electroencephalogram (EEG), has been demonstrated to be altered, suggesting pain-induced neuroplastic changes. More specifically, the relative beta activity (compared to the rest of the brain) is increased, the relative alpha activity is decreased, and the theta activity both absolutely and relatively is diminished.

Dopaminergic dysfunction has been hypothesized to act as a shared mechanism between chronic pain, insomnia and major depressive disorder. Increased tonic dopamine activity and a compensatory decrease in phasic dopamine activity, which is important in inhibiting pain. This is supported by the implication of COMT in fibromyalgia and temporomandibular joint syndrome. Astrocytes, microglia, and Satellite glial cells have been found to be dysfunctional in chronic pain. Increased activity of microglia, alterations of microglial networks as well as increased production of chemokines and cytokines by microglia are proposed to act to potentiate pain. Astrocytes have been observed to lose their ability to regulate the excitability of neurons, increasing spontaneous neural activity in pain circuits.

Management

Pain management is the branch of medicine employing an interdisciplinary approach to the relief of pain and improvement in the quality of life of those living with pain. The typical pain management team includes medical practitioners (particularly anesthesiologists), rehabilitation psychologists, physiotherapists, occupational therapists, physician assistants, and nurse practitioners. Acute pain usually resolves with the efforts of one practitioner; however, the management of chronic pain frequently requires the coordinated efforts of the treatment team. Complete and sustained remission of many types of chronic pain is rare, though some can be done to improve quality of life.

Nonopioids

Initially recommended efforts are non opioid based therapies.

Various nonopioid medicines are used, depending on whether the pain originates from tissue damage or is neuropathic. Limited evidence suggests that chronic pain from tissue inflammation or damage (as in rheumatoid arthritis and cancer pain) is best treated with opioids, while for neuropathic pain (pain caused by a damaged or dysfunctional nervous system) other drugs may be more effective, such as tricyclic antidepressants, serotonin-norepinephrine reuptake inhibitors, and anticonvulsants. Because of weak evidence, the best approach is not clear when treating many types of pain, and doctors must rely on their own clinical experience. Doctors often cannot predict who will use opioids just for pain management and who will go on to develop addiction, and cannot always distinguish between those who are and those who are not seeking opioids due primarily to an existing addiction. Withholding, interrupting or withdrawing opioid treatment in people who benefit from it can cause harm.

Interventional pain management may be appropriate, including techniques such as trigger point injections, neurolytic blocks, and radiotherapy. While there is no high quality evidence to support ultrasound, it has been found to have a small effect on improving function in non-specific chronic low back pain.

Psychological treatments, including cognitive behavioral therapy and acceptance and commitment therapy have been shown effective for improving quality of life and reducing pain interference in those with chronic pain. 

While exercise has been offered as a method to lessen chronic pain and there is some evidence of benefit, this evidence is tentative. Side effects from exercise are few in this population.

Opioids

In those who have not benefited from other measures and have no history of either mental illness or substance use disorder treatment with opioids may be tried. If significant benefit does not occur it is recommended that they be stopped. In those on opioids, stopping or decreasing their use may improve outcomes including pain.

Some people with chronic pain benefit from opioid treatment and others do not; some are harmed by the treatment. Possible harms include reduced sex hormone production, hypogonadism, infertility, impaired immune system, falls and fractures in older adults, neonatal abstinence syndrome, heart problems, sleep-disordered breathing, opioid-induced hyperalgesia, physical dependence, addiction, and overdose.

Alternative medicine

Hypnosis, including self-hypnosis, has tentative evidence. Evidence does not support hypnosis for chronic pain due to a spinal cord injury.

Preliminary studies have found medical marijuana to be beneficial in treating neuropathic pain, but not other kinds of long term pain. As of 2018 even for neuropathic pain the evidence is not strong for any benefit and further research is needed.

Tai Chi has been shown to improve pain, stiffness, and quality of life in chronic conditions such as osteoarthritis, low back pain, and osteoporosis. Acupuncture has also been found to be an effective and safe treatment in reducing pain and improving quality of life in chronic pain including chronic pelvic pain syndrome.

Transcranial magnetic stimulation for reduction of chronic pain is not supported by high quality evidence, and the demonstrated effects are small and short-term.

Epidemiology

A systematic literature review of chronic pain found that the prevalence of chronic pain varied in various countries from 10.1% to 55.2% of the population, affected women at a higher rate than men, and that chronic pain consumes a large amount of healthcare resources around the globe.

A large-scale telephone survey of 15 European countries and Israel, 19% of respondents over 18 years of age had suffered pain for more than 6 months, including the last month, and more than twice in the last week, with pain intensity of 5 or more for the last episode, on a scale of 1 (no pain) to 10 (worst imaginable). 4839 of these respondents with chronic pain were interviewed in depth. Sixty six percent scored their pain intensity at moderate (5–7), and 34% at severe (8–10); 46% had constant pain, 56% intermittent; 49% had suffered pain for 2–15 years; and 21% had been diagnosed with depression due to the pain. Sixty one percent were unable or less able to work outside the home, 19% had lost a job, and 13% had changed jobs due to their pain. Forty percent had inadequate pain management and less than 2% were seeing a pain management specialist.

In the United States, the prevalence of chronic pain has been estimated to be approximately 35%, with approximately 50 million Americans experiencing partial or total disability as a consequence. According to the Institute of Medicine, there are about 116 million Americans living with chronic pain, which suggests that approximately half of American adults have some chronic pain condition. The Mayday Fund estimate of 70 million Americans with chronic pain is slightly more conservative. In an internet study, the prevalence of chronic pain in the United States was calculated to be 30.7% of the population: 34.3% for women and 26.7% for men.

Outcomes

Sleep disturbance, and insomnia due to medication and illness symptoms are often experienced by those with chronic pain. Such co-morbidities can be difficult to treat due to the high potential of medication interactions, especially when the conditions are treated by different doctors.

Severe chronic pain is associated with increased 10 year mortality, particularly from heart disease and respiratory disease. Several mechanisms have been proposed for the increased mortality, e.g. abnormal endocrine stress response. Additionally, chronic stress seems to affect cardiovascular risk by acceleration of the atherosclerotic process. However, further research is needed to clarify the relationship between severe chronic pain, stress and cardiovascular health.

Psychology

Personality

Two of the most frequent personality profiles found in people with chronic pain by the Minnesota Multiphasic Personality Inventory (MMPI) are the conversion V and the neurotic triad. The conversion V personality, so called because the higher scores on MMPI scales 1 and 3, relative to scale 2, form a "V" shape on the graph, expresses exaggerated concern over body feelings, develops bodily symptoms in response to stress, and often fails to recognize their own emotional state, including depression. The neurotic triad personality, scoring high on scales 1, 2 and 3, also expresses exaggerated concern over body feelings and develops bodily symptoms in response to stress, but is demanding and complaining.

Some investigators have argued that it is this neuroticism that causes acute pain to turn chronic, but clinical evidence points the other way, to chronic pain causing neuroticism. When long term pain is relieved by therapeutic intervention, scores on the neurotic triad and anxiety fall, often to normal levels. Self-esteem, often low in people with chronic pain, also shows striking improvement once pain has resolved.

It has been suggested that catastrophizing may play a role in the experience of pain. Pain catastrophizing is the tendency to describe a pain experience in more exaggerated terms than the average person, to think a great deal more about the pain when it occurs, or to feel more helpless about the experience. People who score highly on measures of catastrophization are likely to rate a pain experience as more intense than those who score low on such measures. It is often reasoned that the tendency to catastrophize causes the person to experience the pain as more intense. One suggestion is that catastrophizing influences pain perception through altering attention and anticipation, and heightening emotional responses to pain. However, at least some aspects of catastrophization may be the product of an intense pain experience, rather than its cause. That is, the more intense the pain feels to the person, the more likely they are to have thoughts about it that fit the definition of catastrophization.

Social support

Social support has important consequences for individuals with chronic pain. In particular, pain intensity, pain control, and resiliency to pain has been implicated as outcomes influenced by different levels and types of social support. Much of this research has focused on emotional, instrumental, tangible and informational social support. People with persistent pain conditions tend to rely on their social support as a coping mechanism and therefore have better outcomes when they are a part of larger more supportive social networks. Across a majority of studies investigated, there was a direct significant association between social activities or social support and pain. Higher levels of pain were associated with a decrease in social activities, lower levels of social support, and reduced social functioning.

Effect on cognition

Chronic pain's impact on cognition is an under-researched area, but several tentative conclusions have been published. Most people with chronic pain complain of cognitive impairment, such as forgetfulness, difficulty with attention, and difficulty completing tasks. Objective testing has found that people in chronic pain tend to experience impairment in attention, memory, mental flexibility, verbal ability, speed of response in a cognitive task, and speed in executing structured tasks.

Chronic care

From Wikipedia, the free encyclopedia

 

Chronic care refers to medical care which addresses pre-existing or long term illness, as opposed to acute care which is concerned with short term or severe illness of brief duration. Chronic medical conditions include asthma, diabetes, emphysema, chronic bronchitis, congestive heart disease, cirrhosis of the liver, hypertension and depression. Without effective treatment chronic conditions may lead to disability.

The incidence of chronic disease has increased as mortality rates have decreased. It is estimated that by 2030 half of the population of the USA will have one or more chronic conditions.

Conditions, injuries and diseases which were previously fatal can now be treated with chronic care. Chronic care aims to maintain wellness by keeping symptoms in remission while balancing treatment regimes and quality of life. Many of the core functions of primary health care are central to chronic care. Chronic care is complex in nature because it may extend over a pro-longed period of time, requires input from a diverse set of health professionals, various medications and possibly monitoring equipment.

Policy making

According to 2008 figures from the Centers for Disease Control and Prevention chronic medical care accounts for more than 75% of health care spending in the US. In response to the increased government expenditure in dealing with chronic care policy makers are searching for effective interventions and strategies. These strategies can broadly be described within four categories. These are disease prevention and early detection, new providers, settings and qualifications, disease management programs and integrated care models.

Challenges

One of the major problems from a health care system which is poorly coordinated for sufferers of chronic conditions is the incidence of patients receiving conflicting advice from different providers. Patients will often be given prescriptions for medication that adversely interact with one another. One recent study estimated that more than 20% of older patients in the USA took at least one medication which could negatively impact another condition. This is referred to as therapeutic competition.

Effective chronic care requires an information platform to track patients' status and ensure appropriate treatments are given.

There is a recognised gap between treatment guidelines and current practice for chronic care. Individualised treatment plans are critical in treating chronic conditions because patients will place varying important on health outcomes. For example, some patients will fore-go complex, inconvenient medication regimes at the expense of quality of life.

Multiple conditions

One of the greatest challenges in this field of health care is dealing with the co-existence of multiple disorders, which is called multi-morbidity. There are few incentives within current health care systems to coordinate care across multiple providers and varying services. A 2001 survey by Mathematica Policy Research found that physicians feel they have inadequate training to deal with multiple chronic conditions. An increase in the number of chronic conditions correlates with an increase in the number of inappropriate hospitalizations. Self-management can be challenging because recommended activities for one condition may be made difficult because of another condition.

Approaches

A nurse has to be qualified to handle all the needs of a chronic client and has to be an advocate to put the case of the chronically ill across to the health administration, hospital board or their families. 

A variety of specialists such as surgeons, dietitians, nutritionists, and occupational therapists have to be in attendance for the maximum benefit of the client. Someone suffering from chronic pain for a long time may need the help of a psychiatrist. Everyday activities that the physically fit see as normal may be a Herculean feat for the chronically ill and they need all the support that they can get. The nurse may be privy to some of these help that the chronically ill can benefit from. They need to be proactive and put these patients in contact with these help but also sensitive enough to give their client the freedom to decline any help if they think that they do not need it. 

Chronic pain might also get the person to start questioning their faith and/or wanting to have a deeper spiritual experience because of their pain and suffering.

The patient also needs to take time to participate in some fun activities. They may need to check out of the facility/hospital or get out of the house occasionally preventing an association of hospitals with pain. This further helps the patients keep their sanity and keeps them psychologically sound. 

They may need a nurse who is qualified in palliative care. Some may be dying and they need respect and dignity as they die in pain. They also need a nurse who is non-judgmental and one who is also compassionate and caring. The family has to be involved to help the client better manage the pain. One very important quality is co-ordinating the best care for the client and some amount of diplomacy and empathy. 

In some cases, such as with diabetes or sleep apnea, the treatment is long term and difficult for patients to understand and comply with. In these cases chronic care management is highly recommended to help the patient learn about the consequences of refusing treatment and how to best follow treatment.

Health professional

From Wikipedia, the free encyclopedia
 

A health professional may operate within all branches of health care, including medicine, surgery, dentistry, midwifery, pharmacy, psychology, nursing or allied health professions. A health professional may also be a public/community health expert working for the common good of the society.

Practitioners and professionals

Health practitioners and professionals
Athletic trainer Audiologist Chiropractor Clinical coder Clinical nurse specialist Clinical officer Community health worker Dentist Dietitian and nutritionist Emergency medical technician Feldsher Health administrator Medical assistant Medical laboratory scientist Medical transcriptionist Nurse anesthetist Nurse practitioner Nurse midwife Nurse Occupational Therapist Optometrist Paramedic Pharmacist Pharmaconomist Pharmacy technician Phlebotomist Physician Physician assistant Podiatrist Psychologist Psychotherapist Physical therapist Radiographer Radiotherapist Respiratory therapist Speech-language pathologist Surgeon Surgeon's assistant Surgical technologist

The healthcare workforce comprises a wide variety of professions and occupations who provide some type of healthcare service, including such direct care practitioners as physicians, nurses, surgeons, dentists, physical and behavior therapists, as well as allied health professionals such as phlebotomists, medical laboratory scientists, dieticians, and social workers. They often work in hospitals, healthcare centres and other service delivery points, but also in academic training, research, and administration. Some provide care and treatment services for patients in private homes. Many countries have a large number of community health workers who work outside formal healthcare institutions. Managers of healthcare services, health information technicians, and other assistive personnel and support workers are also considered a vital part of health care teams.

Healthcare practitioners are commonly grouped into health professions. Within each field of expertise, practitioners are often classified according to skill level and skill specialization. “Health professionals” are highly skilled workers, in professions that usually require extensive knowledge including university-level study leading to the award of a first degree or higher qualification. This category includes physicians, physician assistants, dentists, midwives, radiographers, registered nurses, pharmacists, physiotherapists, optometrists, operating department practitioners and others. Allied health professionals, also referred to as "health associate professionals" in the International Standard Classification of Occupations, support implementation of health care, treatment and referral plans usually established by medical, nursing, and other health professionals, and usually require formal qualifications to practice their profession. In addition, unlicensed assistive personnel assist with providing health care services as permitted. 

Another way to categorize healthcare practitioners is according to the sub-field in which they practice, such as mental health care, pregnancy and childbirth care, surgical care, rehabilitation care, or public health.

Mental health practitioners

A mental health practitioner is a health worker who offers services for the purpose of improving the mental health of individuals or treating mental illness. These include psychiatrists, clinical psychologists, clinical social workers, psychiatric-mental health nurse practitioners, marriage and family therapists, mental health counselors, as well as other health professionals and allied health professions. These health care providers often deal with the same illnesses, disorders, conditions, and issues; however their scope of practice often differs. The most significant difference across categories of mental health practitioners is education and training.

Maternal and newborn health practitioners

A maternal and newborn health practitioner is a health worker who deals with the care of women and their children before, during and after pregnancy and childbirth. Such health practitioners include obstetricians, midwives, obstetrical nurses and many others. One of the main differences between these professions is in the training and authority to provide surgical services and other life-saving interventions. In some developing countries, traditional birth attendants, or traditional midwives, are the primary source of pregnancy and childbirth care for many women and families, although they are not certified or licensed.

Geriatric care practitioners

A geriatric care practitioner plans and coordinates the care of the elderly and/or disabled to promote their health, improve their quality of life, and maintain their independence for as long as possible. They include geriatricians, adult-gerontology nurse practitioners, clinical nurse specialists, geriatric clinical pharmacists, geriatric nurses, geriatric care managers, geriatric aides, Nursing aides, Caregivers and others who focus on the health and psychological care needs of older adults.

Surgical practitioners

A surgical practitioner is a healthcare professional who specializes in the planning and delivery of a patient's perioperative care, including during the anaesthetic, surgical and recovery stages. They may include general and specialist surgeons, surgeon's assistant, assistant surgeon, surgical assistant, anesthesiologists, anesthesiologist assistant, nurse anesthetists, surgical nurses, clinical officers, operating department practitioners, anaesthetic technicians, perioperative nursing, surgical technologists, and others.

Rehabilitation care practitioners

A rehabilitation care practitioner is a health worker who provides care and treatment which aims to enhance and restore functional ability and quality of life to those with physical impairments or disabilities. These include physiatrists, rehabilitation nurses, clinical nurse specialists, nurse practitioners, physiotherapists, orthotists, prosthetists, occupational therapists, recreational therapists, audiologists, speech and language pathologists, respiratory therapists, rehabilitation counsellors, physical rehabilitation therapists, athletic trainers, physiotherapy technicians, orthotic technicians, prosthetic technicians, personal care assistants, and others.

Eye care practitioners

Care and treatment for the eye and the adnexa may be delivered by ophthalmologists specializing in surgical/medical care, or optometrists specializing in refractive management and medical/therapeutic care.

Medical diagnosis providers

Medical diagnosis providers are health workers responsible for the process of determining which disease or condition explains a person's symptoms and signs. It is most often referred to as diagnosis with the medical context being implicit. This usually involves a team of healthcare providers in various diagnostic units. These include radiographers, radiologists, medical laboratory scientists, pathologists, and related professionals.

Oral care practitioners

A dental care practitioner is a health worker who provides care and treatment to promote and restore oral health. These include dentists and dental surgeons, dental assistants, dental auxiliaries, dental hygienists, dental nurses, dental technicians, dental therapists or oral health therapists, and related professionals.

Foot care practitioners

Care and treatment for the foot, ankle, and lower leg may be delivered by podiatrists, chiropodists, pedorthists, foot health practitioners, podiatric medical assistants, podiatric nurse and others.

Public health practitioners

A public health practitioner focuses on improving health among individuals, families and communities through the prevention and treatment of diseases and injuries, surveillance of cases, and promotion of healthy behaviors. This category includes community and preventive medicine specialists, public health nurses, clinical nurse specialists, dietitians, environmental health officers, paramedics, epidemiologists, health inspectors, and others.

Alternative medicine practitioners

In many societies, practitioners of alternative medicine have contact with a significant number of people, either as integrated within or remaining outside the formal health care system. These include practitioners in acupuncture, Ayurveda, herbalism, homeopathy, naturopathy, Reiki, Shamballa Reiki energy healing, Siddha medicine, traditional Chinese medicine, traditional Korean medicine, Unani, and Yoga. In some countries such as Canada, chiropractors and osteopaths (not to be confused with doctors of osteopathic medicine in the United States) are considered alternative medicine practitioners.

Practice conditions and regulations

Shortages of health professionals

Many jurisdictions report shortfalls in the number of trained health human resources to meet population health needs and/or service delivery targets, especially in medically underserved areas. For example, in the United States, the 2010 federal budget invested $330 million to increase the number of doctors, nurses, and dentists practicing in areas of the country experiencing shortages of trained health professionals. The Budget expands loan repayment programs for physicians, nurses, and dentists who agree to practice in medically underserved areas. This funding will enhance the capacity of nursing schools to increase the number of nurses. It will also allow states to increase access to oral health care through dental workforce development grants. The Budget’s new resources will sustain the expansion of the health care workforce funded in the Recovery Act. There were 15.7 million health care professionals in the US as of 2011.

In Canada, the 2011 federal budget announced a Canada Student Loan forgiveness program to encourage and support new family physicians, nurse practitioners and nurses to practice in underserved rural or remote communities of the country, including communities that provide health services to First Nations and Inuit populations.

In Uganda, the Ministry of Health reports that as many as 50% of staffing positions for health workers in rural and underserved areas remain vacant. As of early 2011, the Ministry was conducting research and costing analyses to determine the most appropriate attraction and retention packages for medical officers, nursing officers, pharmacists, and laboratory technicians in the country’s rural areas.

At the international level, the World Health Organization estimates a shortage of almost 4.3 million doctors, midwives, nurses, and support workers worldwide to meet target coverage levels of essential primary health care interventions. The shortage is reported most severe in 57 of the poorest countries, especially in sub-Saharan Africa.

Occupational hazards

A healthcare professional wears an air sampling device to investigate exposure to airborne influenza

The healthcare workforce face unique health and safety challenges and is recognized by the National Institute for Occupational Safety and Health (NIOSH) as a priority industry sector in the National Occupational Research Agenda (NORA) to identify and provide intervention strategies regarding occupational health and safety issues.

Occupational stress and occupational burnout are highly prevalent among health professionals. Some studies suggest that workplace stress is pervasive in the health care industry because of inadequate staffing levels, long work hours, exposure to infectious diseases and hazardous substances leading to illness or death, and in some countries threat of malpractice litigation. Other stressors include the emotional labor of caring for ill people and high patient loads. The consequences of this stress can include substance abuse, suicide, major depressive disorder, and anxiety, all of which occur at higher rates in health professionals than the general working population. Elevated levels of stress are also linked to high rates of burnout, absenteeism and diagnostic errors, and to reduced rates of patient satisfaction. In Canada, a national report (Canada's Health Care Providers) also indicated higher rates of absenteeism due to illness or disability among health care workers compared to the rest of the working population, although those working in health care reported similar levels of good health and fewer reports of being injured at work. There is some evidence that cognitive-behavioral therapy, relaxation training and therapy (including meditation and massage), and modifying schedules can reduce stress and burnout among multiple sectors of health care providers. Research is ongoing in this area, especially with regards to physicians, whose occupational stress and burnout is less researched compared to other health professions.

Exposure to respiratory infectious diseases like tuberculosis (caused by Mycobacterium tuberculosis) and influenza can be reduced with the use of respirators; this exposure is a significant occupational hazard for health care professionals. Exposure to dangerous chemicals, including chemotherapy drugs, is another potential occupational risk. These drugs can cause cancer and other health conditions. Healthcare workers are also at risk for diseases that are contracted through extended contact with a patient, including scabies. Health professionals are also at risk for contracting blood-borne diseases like hepatitis B, hepatitis C, and HIV/AIDS through needlestick injuries or through contact with bodily fluids. This risk can be mitigated with vaccination when there is a vaccine available, like with hepatitis B. In epidemic situations, such as the 2014-2016 West African Ebola virus epidemic or the 2003 SARS outbreak, healthcare workers are at even greater risk, and were disproportionately affected in both the Ebola and SARS outbreaks. In general, appropriate personal protective equipment (PPE) is the first-line mode of protection for healthcare workers from infectious diseases. For it to be effective against highly contagious diseases, personal protective equipment must be watertight and prevent the skin and mucous membranes from contacting infectious material. Different levels of personal protective equipment created to unique standards are used in situations where the risk of infection is different. Practices such as triple gloving and multiple respirators do not provide a higher level of protection and present a burden to the worker, who is additionally at increased risk of exposure when removing the PPE. Compliance with appropriate personal protective equipment rules may be difficult in certain situations, such as tropical environment or low-resource settings. A 2016 Cochrane systematic review found low quality evidence that using more breathable fabric in PPE, double gloving, and active training reduce the risk of contamination.

Female health care workers may face specific types of workplace-related health conditions and stress. According to the World Health Organization, women predominate in the formal health workforce in many countries, and are prone to musculoskeletal injury (caused by physically demanding job tasks such as lifting and moving patients) and burnout. Female health workers are exposed to hazardous drugs and chemicals in the workplace which may cause adverse reproductive outcomes such as spontaneous abortion and congenital malformations. In some contexts, female health workers are also subject to gender-based violence including from coworkers and patients.

Healthcare workers are at higher risk of on-the-job injury due to violence. Drunk, confused, and hostile patients and visitors are a continual threat to providers attempting to treat patients. Frequently, assault and violence in a healthcare setting goes unreported and is wrongly assumed to be part of the job. Violent incidents typically occur during one-on-one care; being alone with patients increases healthcare workers' risk of assault. In the United States, healthcare workers suffer ⅔ of nonfatal workplace violence incidents. Psychiatric units represent the highest proportion of violent incidents, at 40%; they are followed by geriatric units (20%) and the emergency department (10%). Workplace violence can also cause psychological trauma.

Slips, trips, and falls are the second-most common cause of worker's compensation claims in the US, and cause 21% of work absences due to injury. These injuries most commonly result in strains and sprains; women, those older than 45, and those who have been working less than a year in a healthcare setting are at the highest risk.

Health care professionals are also likely to experience sleep deprivation due to their jobs. Many health care professionals are on a shift work schedule, and therefore experience misalignment of their work schedule and their circadian rhythm. In 2007, 32% of healthcare workers were found to get fewer than 6 hours of sleep a night. Sleep deprivation also predisposes healthcare professionals to make mistakes that may potentially endanger a patient.

An epidemiological study published in 2018 examined the hearing status of noise-exposed health care and social assistance (HSA) workers sector to estimate and compare the prevalence of hearing loss by subsector within the sector.  Most of the HSA subsector prevalence estimates ranged from 14% to 18%, but the Medical and Diagnostic Laboratories subsector had 31% prevalence and the Offices of All Other Miscellaneous Health Practitioners had a 24% prevalence. The Child Day Care Services subsector also had a 52% higher risk than the reference industry.

Regulation and registration of professionals

Practicing without a license that is valid and current is typically illegal. In most jurisdictions, the provision of health care services is regulated by the government. Individuals found to be providing medical, nursing or other professional services without the appropriate certification or license may face sanctions and criminal charges leading to a prison term. The number of professions subject to regulation, requisites for individuals to receive professional licensure, and nature of sanctions that can be imposed for failure to comply vary across jurisdictions.

In the United States, under Michigan state laws, an individual is guilty of felony if identified as practicing in the health profession without a valid personal license or registration. Health professionals can also be imprisoned if found guilty of practicing beyond the limits allowed by their licences and registration. The state laws define the scope of practice for medicine, nursing, and a number of allied health professions. In Florida, practicing medicine without the appropriate license is a crime classified as a third degree felony, which may give imprisonment up to five years. Practicing a health care profession without a license which results in serious bodily injury classifies as a second degree felony, providing up to 15 years' imprisonment.

In the United Kingdom, healthcare professionals are regulated by the state; the UK Health and Care Professions Council (HCPC) protects the 'title' of each profession it regulates. For example, it is illegal for someone to call himself an Occupational Therapist or Radiographer if they are not on the register held by the HCPC.