10-Minute Mini Lesson Four:  Scheduling Fun, Enjoyment, and Achievement

10-Minute Mini Lesson Four is designed to provide a basic understanding of how to help members set schedule fun, enjoyment, and achievement as part of their pain management treatment.

IS LAUGHTER THE BEST MEDICINE?

For years, humor has been used in medicine. Surgeons used humor to distract patients from pain as early as the 13th century. Later, in the 20th century, came the scientific study of the effect of humor on physical wellness. Many credit this to Norman Cousins. After years of prolonged pain from a serious illness, Cousins claims to have cured himself with a self-invented regimen of laughter and vitamins. In his 1979 book Anatomy of an Illness, Cousins describes how watching comedic movies helped him recover.

Over the years, researchers have conducted studies to explore the impact of laughter on health. According to some studies, laughter therapy may provide physical benefits, such as helping to:

• Boost the immune system and circulatory system
• Enhance oxygen intake
• Stimulate the heart and lungs
• Relax muscles throughout the body
• Trigger the release of endorphins (the body’s natural painkillers)
• Ease digestion/soothes stomach aches
• Relieve pain
• Balance blood pressure
• Improve mental functions (i.e., alertness, memory, creativity)

Laughter therapy may also help to:

• Improve overall attitude
• Reduce stress/tension
• Promote relaxation
• Improve sleep
• Enhance quality of life
• Strengthen social bonds and relationships
• Produce a general sense of well-being

Today more than ever before, people are turning to humor for therapy and healing.

FIVE EXERCISES FOR LAUGHTER THERAPY:

1. Humming Laughter Sounds: Laugh as you hum, mouth closed. Play with the pitch, up and down the scale, feeling the vibrations resonate through your body. As you get more adapt at feeling the resonation, try and move it deliberately, through your chest, your jaw, your nose, your sinus cavities, your forehead, the top of your head, then back down again.
2. Laughter Breath: Inhale deeply, and then exhale in a combination of first quick bursts of air coming out and finishing with vocal laughter. Repeat 5-7 times.
3. Laughter Vowels: Laugh the sound of the following laughter vowels. Let’s start with: “A” as in “papa”: Aaaaa ha ha ha ha ha. Then “E” as in “free”: Eeeee he he he he he. Next is “I” as in “pie”: iiiii hi hi hi hi hi. Next is “O” as in “Bingo”: Ooooo ho ho ho ho ho. Last is “U” as in “soup”: Uuuuu hu hu hu hu hu. Excellent! Now repeat, but backwards.
4. Happy Memories Chuckle: Go back in time and find a truly happy memory, typically of a time when you felt safe, loved, surrounded by people you loved, and when you all laughed. Take time to connect with this memory, laughing now as if you were back then. It normally takes 90-120 seconds to start to recreate the associated emotions.
5. Hearty Laughter: Make an elongated “aeeee” sound as you slowly lift both arms all the way up, and then laugh heartily with your hands pointed to the sky. Imagine that your laughter is coming straight from your heart.

HOW TO ENJOY LIFE IN SPITE OF PAIN:

Suggestions from real patients at HOW TO COPE WITH PAIN:

I know the pain was going to be there but if I could get out and go places and do things I could still have some kind of life. My husband got me a mobility scooter. I am still restricted as to when I can get out but I do get out.

It is very difficult to maintain a positive attitude when all you feel is pain. Continue everyday being positive and keep going your family and friends need you. Breathe. Exercise. Pray. Diversions. Win your pain battle every hour.

I have a couple hours of the day when I can do a little bit and try to take advantage of cramming fun stuff into those few minutes here and there.
SUGGESTIONS FOR FINDING NEW WAYS TO MEASURE ACHIEVEMENT:

Tell your patients to treasure their big life achievements like graduating from school, getting that promotion, or finding the perfect life partner BUT when battling pain suggest that they DO NOT set that level of accomplishment as a goal.

Instead, they can consider each and every daily life activity as an accomplishment. Here are ten they can start with:

1. Waking up
2. Brushing my teeth
3. Preparing one food item and eating it
4. Patting the dog
5. Calling a friend
6. Typing my own shoes
7. Remembering to fill a prescription
8. Sitting outside for 15 minutes
9. Enjoying a TV program
10. Being grateful for the first nine!

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AS A REMINDER (from the Introduction to this series on CBT for pain management in the primary care office):

CBT is the “gold standard” psychological treatment for individuals with a wide range of pain problems. It can reduce pain, distress, pain interference with activities, and disability. And it may well have positive benefits for common comorbid conditions such as depression, diabetes, and cardiovascular disease. It has been shown to be effective regardless of the particular licensing or background of the provider, as long as they have an understanding of basic CBT concepts and skills, and can even be effective in web-based applications. Brief in-office CBT is not designed to replace referral to a professional mental health provider with his/her diagnostic skills and therapy and/or medication options when this seems more appropriate.

CBT is not just for the licensed behaviorist! These CBT Mini Lessons can be used by:

1. The PCP him/herself (using appropriate billing codes to cover the extra 5-10 minutes),
2. Office staff such as nurses, medical assistants, behavioral health providers (using Health & Behavior codes billed to PHC)
3. A co-located Beacon-credentialed behavioral health provider (billed to Beacon)

Having practiced as a cognitive behavioral therapist for 40 years, I’ve seen CBT techniques used effectively in individual and group settings, in both clinical and psycho-educational venues, and provided by both professional and para-professional providers.

What are the advantages of bringing CBT into the primary care office?

1. PCP is best qualified to understand Member’s medical history and current needs.
2. Interventions are made when the Member is most motivated for change, i.e., the very moment when they are asking for help
3. Providing behavioral alternatives allows the PCP to manage the Member’s pain more safely
4. CBT interventions with home practice recommendations and handouts are quite effective in the primary care setting
5. Avoid the stigma and wait time sometimes associated with referral to a behavioral health specialist

What are the basic goals for using CBT for pain management?

1. Improved relationship with health professional—Member not shuffled off elsewhere, workable alternatives to medication changes
2. Increased functional activities—Focus changes from Member saying, “I can’t…” to Member asking, “How can I…?”
3. Improved mood and quality of life—Decreased depression, more optimism and self-confidence, less risk of side effects from medication
4. Improved symptom control—Better awareness of pain cycles, reducing use of unworkable strategies for managing pain
5. Improved self-management—Reliance on self rather than others to provide solutions
6. Reduction in unnecessary visits—Reliable self-management options rather than unnecessary appointments when pain increases

By Karen Stephen, Ph.D., PHC Mental Health Clinical Director

10-Minute Mini Lesson Three:  Goal Setting

10-Minute Mini Lesson Three is designed to provide a basic understanding of how to help members set achievable goals as part of their pain management treatment.

WHAT MAKES GOAL-SETTING DIFFICULT?

Most of us are good at identifying changes we would like to see in our lives. However, effecting these changes is often more difficult than identifying what they are — easier said than done, as they say!

Sometimes we feel overwhelmed by the size of the goal before us, and we simply do not know where to start. Other times we try to achieve a goal, but it just doesn’t work out. In these situations, it’s easy to feel discouraged and give up.

USING THE ACRONYM “SMART”:

The acronym SMART can be an important part of identifying appropriate goals and steps. This stands for:

Specific. Suggest patients be as specific as possible so they can tell when they have completed a goal or step. “Get more exercise” is vague, but “Walk around the block on Monday, Wednesday, and Friday” can be easily checked off.

Measurable. Suggest they make goals and steps measurable. Then they can track their progress over time. In the example above, specifying the “3 days” gives them a way to measure any change in their exercise habits.

Achievable. Make sure they pick a goal they can actually be attained. If it is NOT achievable then suggest they select a smaller step. For example, “Walk to the corner and back on Monday and Friday”

THE PRIMARY LAW OF CHANGE: If they are NOT achieving their goal, they haven’t selected a SMALL ENOUGH step.

Relevant. Make sure the goal they have chosen is in line with what they want to accomplish overall. Learning to be a better public speaker is a great goal, but perhaps not the most relevant if your greater aim is to make more friends.

Timely. Make sure that now is a good time to work toward their goal. For example, are they physically able to walk to the corner or around the block? This may have to wait until they have a walker or more strength in their legs.

HERE IS AN EXAMPLE OF GOAL SETTING:

Tom has been very athletic in the past and is very depressed about being relegated to his recliner because of his pain. He comes in with the goal of being able to take his usual five-mile run in the morning.

1. ACKNOWLEDGE HIS OVERALL GOAL of returning to his usual exercise regime.
2. Help him IDENTIFY A START POINT. He needs to be honest and ask himself, “Where do things stand now?” His answer: I can walk to the bathroom or kitchen. I need to rest after 5 minutes of walking or the pain is too much.
3. Help him break down his “goal” by IDENTIFYING ALL OF THE STEPS it would take to get from his start point to his goal. Suggestions that could be made to Tom:
4. Track how many times you walk to the bathroom or kitchen. Increase that by 2-3 more trips each day. Remember that EACH trip matters as a step toward your goal. These early steps are important. Congratulate yourself.
5. Add walking outside (e.g., to the backyard, front yard, or outdoor hallway) but limit it to 5 minutes. Do this with a partner if it seems scary to you.
6. Time your trips and add ONE minute each day. This means you would more than double your stamina in less than a week.
7. Track all your trips and times. This is your training schedule and will help you reach your goal.
8. Once a day, do more than what you think you can do. Then you can feel proud of yourself for going above and beyond.
9. Help him CONSIDER POTENTIAL OBSTACLES and how to work through or around them:
10. He says, “I can’t imagine going outside.” Suggestion: Suit up, put on your walking shoes, and just stand outside your front door. This is the trick: Almost everyone goes for the walk once they are outside their front door.
11. He says, “But it hurts too much.” Suggestion: Remind him that the pain could lessen once he gets his body more active or that he can hurt on a walk as easily as he can hurt in his recliner and it will be more fun and more distracting from the pain. Ask what he’d like to see on his walk—a good way to encourage getting outside.
12. He says, “I’m afraid I’ll fall.” Suggestion: This is a realistic concern. Offer to help him obtain whatever walking aid would decrease his fears.

CAN GOAL SETTING HELP IN ADDRESSING EMOTIONAL OR BEHAVIORAL DIFFICULTIES?

Goal setting can also be helpful when addressing emotional or behavioral difficulties. For example, someone who is depressed and isolated may work toward a goal of increasing the number and strength of his friendships. Someone experiencing anxiety related to her job may work toward exploring a career change or making time more often for relaxation and leisure. Because goal setting strategies are often used in CBT, this therapeutic approach is particularly helpful for those struggling to meet their goals, regardless of what those goals may be.

*************************************************************************

AS A REMINDER (from the Introduction to this series on CBT for pain management in the primary care office):

CBT is the “gold standard” psychological treatment for individuals with a wide range of pain problems. It can reduce pain, distress, pain interference with activities, and disability. And it may well have positive benefits for common comorbid conditions such as depression, diabetes, and cardiovascular disease. It has been shown to be effective regardless of the particular licensing or background of the provider, as long as they have an understanding of basic CBT concepts and skills, and can even be effective in web-based applications. Brief in-office CBT is not designed to replace referral to a professional mental health provider with his/her diagnostic skills and therapy and/or medication options when this seems more appropriate.

CBT is not just for the licensed behaviorist! These CBT Mini Lessons can be used by:

1. The PCP him/herself (using appropriate billing codes to cover the extra 5-10 minutes),
2. Office staff such as nurses, medical assistants, behavioral health providers (using Health & Behavior codes billed to PHC)
3. A co-located Beacon-credentialed behavioral health provider (billed to Beacon)

Having practiced as a cognitive behavioral therapist for 40 years, I’ve seen CBT techniques used effectively in individual and group settings, in both clinical and psycho-educational venues, and provided by both professional and para-professional providers.

What are the advantages of bringing CBT into the primary care office?

1. PCP is best qualified to understand Member’s medical history and current needs.
2. Interventions are made when the Member is most motivated for change, i.e., the very moment when they are asking for help
3. Providing behavioral alternatives allows the PCP to manage the Member’s pain more safely
4. CBT interventions with home practice recommendations and handouts are quite effective in the primary care setting
5. Avoid the stigma and wait time sometimes associated with referral to a behavioral health specialist

What are the basic goals for using CBT for pain management?

1. Improved relationship with health professional—Member not shuffled off elsewhere, workable alternatives to medication changes
2. Increased functional activities—Focus changes from Member saying, “I can’t…” to Member asking, “How can I…?”
3. Improved mood and quality of life—Decreased depression, more optimism and self-confidence, less risk of side effects from medication
4. Improved symptom control—Better awareness of pain cycles, reducing use of unworkable strategies for managing pain
5. Improved self-management—Reliance on self rather than others to provide solutions
6. Reduction in unnecessary visits—Reliable self-management options rather than unnecessary appointments when pain increases

FUTURE BLOGS on CBT for Chronic Pain in the PRIMARY CARE OFFICE:

10 Minute Mini Lesson Four – Scheduling Fun, Enjoyment, and Achievement

By Karen Stephen, Ph.D., PHC Mental Health Clinical Director

My last blog was about the life of a mosquito and Zika concerns.  Now how to avoid mosquito bites

“He told many remarkable things about those lawless insects. Among others, said he had seen them try to vote.” – Mark Twain, Life on the Mississippi

According to the Travel site of the CDC here is some advice.

General avoidance and protection.

Don’t go there.  No really, don’t go there.  – avoid travel to outbreak areas.  The CDC traveler’s website has information.   An unfortunate intersection for the Brazil Summer Olympics.

Avoid peak traffic hours – some mosquitos are dawn and dusk feeders, crepuscular.  But others, including the concerning Aedes albopictus (Asian tiger mosquito), a possible vector for Zika is a daytime feeder.

Protective clothing – obvious enough.  There are also available topically applied clothing (tent, shoes, camping gear) repellants and manufacturer infused insect repellant clothing.  These repellants contain permethrin and the manufacturer infused brands can remain active through several washings.   The topical permethrins have shorter activity.

Spatial protection

Spatial repellants and insecticides have been available and new products are available.  Spatial preventive measures intercept mosquitos prior to human approach.  Closing the doors and windows are an example as are mosquito netting in malarial environs.  Fans discourage the weak flying mosquito and disperse the chemical into which they home.

Spatial repellants and insecticides have been available and new products are available.  Devices that envelop an area or individual in repellent clouds.  Big clouds, small clouds, walking, wind, bug density …  These include coils, candles, foggers and personal devices that vaporize repellants such as metofluthrin.  These devices have not been fully reviewed but under the right conditions likely are helpful.

There are also electronic insect repellent devices which produce sounds that were developed to keep away mosquitos. No EPA or other scientific research has ever sought evidence that these are effective.

Topical Repellants

“I am rather like a mosquito in a nudist camp; I know what I ought to do, but I don’t know where to begin.” – Stephen Bayne

These are the familiar agents.  Off, Cutter, Sawyer, Ultrathon, Skin So Soft, and the like.  Protection time varies by agent, form, ambient temperature, activity level, exposure to sweat and water and abrasion.

The best known repellant is DEET (N,N-diethy-m-tolua-mide).  The CDC recommends using products with > 20% DEET, with effectives that plateaus at about 50%.  Micronized formulations may last longer.  Other products registered with the EPA include those is picaridin, IR3535 and some oil of lemon eucalyptus (formulated as a repellant) and para-methane-diol (artificial OLE) products. Researchers at New Mexico State University tested ten commercially available products for their effectiveness at repelling mosquitoes.  On the mosquito Aedes aegypti, the vector of Zika virus, only one repellent that did not contain DEET had a strong effect for the duration of the 240 minutes test: a lemon eucalyptus oil repellent. All DEET-containing mosquito repellents were active.

The CDC recommendations for repellants

• Apply only to exposed skin and clothing (not under clothing)
• Never to open, irritated skin
• Never to eyes, mouth and sparingly to the ears (for the face apply to hands then transfer to face). The same transfer to apply to kid
• Have kids wash their hands afterwards
• Just enough to cover –thick application does not last longer
• Wash when protection is no longer needed or in case of an allergic reaction

EPA registered products can be used by kids and pregnant or nursing women according to labelling.  DEET should not be used in children under 2 months of age and OLE products on kids less than 3 years old.

You can use both sunscreen (first applied) and repellant at the same time although the reapplication times may make this tricky and the same applies to combination products where the sunscreen may wear off first.

Ironically, the high pitched whine of the mosquito (The Mosquito) has been used as deterrent to human loitering and in high crime areas.  High pitched emissions target a younger, and presumably more delinquent, group with more acute hearing. The Council of Europe considers the device degrading and discriminatory to youngsters and has targeted the U.K. having more that 3,500 such devices in the country.  So that’s why the Brexit!

“Even a mosquito doesn’t get a slap on the back until it starts to work.”

Anyone who thinks that they are too small to make a difference has never tried to fall asleep with a mosquito in the room  – Christine Todd Whitman

Not to confuse, or perhaps to confuse etymology and entomology when you put together the Spanish for fly – mosca and the diminutive suffix –ito together you get mosquito.  A topic, an insect, of great interest in this, the possible summer of Zika.

The mosquito species of interest are the Aedes species – aegypti and albopictus (Asian tiger mosquito).  The former as a known vector of arboviruses in the United States with a limited geographic range and albopictus as a possible, unquantified vector but with a wider range.

The range of the mosquito is limited by winter temperatures – isotherms – but exceptions exist, particularly in urban areas where species can winter in protected environments.

In the vector map below by Gardner, et. al., the solid circles represent the suitable habitat and relative risk for Aedes aegypti and clear circles Aedes albopictus with larger concentric circles representing higher total estimated relative risk.  If you want to be mosquito free, move to Iceland, where both the cold temperatures and weather unpredictability are hostile to establishing a mosquito population.

The life-cycle of the mosquito runs the typical egg-larvae-pupae- adult stages.  The Aedes species can breed in casual puddles such as artificial water containers, cupped leaves, bromeliad axils or notoriously in abandoned spare tires (with the curious physics that have them become upright in marshes).  The eggs are also resistant to drying out and can enter diapause for several months if they dry out.  The male of the species is a nectar feeding insect as is the female, until it is time to breed.  A blood meal is needed to produce eggs.  Different species prefer different hosts such as animals, birds, cold-blooded animals, insects, even fish.

Female mosquitos hunt their hosts by detecting CO2, visual recognition and body chemicals, in particular octenol produced by the host.  Some unfortunate people are just genetically predetermined targets for mosquitos (we all know these people if you are not one of them).  Preferred targets include type O blood, heavy breathers, those with a lot of skin bacteria, body heat and the pregnant.   The antennae of mosquitos have 72 types of odor receptors, 27 are represented by chemicals in sweat.  The male mosquito has bushy auditory receptors to hear the whine of the female (this paraphrase is from Wikipedia- really).

Most mosquitoes are crepuscular hunters – dawn and dusk – ominously the Asian tiger mosquito (a potential Zika vector) is a daytime feeder.   Upon feeding the mosquito injects saliva as an anticoagulant.  This serves as the transmission fluid for arboviruses such as Zika.  The irritating and itchy bite is the result of histamine release in response to the bite.

Next Blog – How to protect yourself from mosquitos