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EDUCATION & TRAINING SECTION Pain Psychology Pain Medicine 2016; 17: 250–263 doi: 10.1093/pm/pnv095 EDUCATION & TRAINING SECTION Original Research Article Pain Psychology: A Global Needs Assessment and National Call to Action Beth D. Darnall, PhD,*,a Judith Scheman, PhD,†,a Design. Prospective, observational, cross-sectional. Sara Davin, PhD,†,b John W. Burns, PhD,‡,b §,b ¶,b Jennifer L. Murphy, PhD, Anna C. Wilson, PhD, Methods. Brief surveys were administered online to Robert D. Kerns, PhD,k and ,a six stakeholder groups (psychologists/therapists, Sean C. Mackey, MD, PhD,* individuals with chronic pain, pain physicians, pri- mary care physicians/physician assistants, nurse *Stanford University School of Medicine, Department practitioners, and the directors of graduate and of Anesthesiology, Perioperative and Pain Medicine, postgraduate psychology training programs). Division of Pain Medicine, Stanford Systems Neuroscience and Pain Laboratory, Palo Alto, Results. 1,991 responses were received. Results California; †Center for Neurological Restoration, revealed low confidence and low perceived compe- Cleveland Clinic, Cleveland, Ohio; ‡Department of tency to address physical pain among psycholo- gists/therapists, and high levels of interest and need Behavioral Sciences, Rush University, Chicago, for pain education. We found broad support for pain Illinois; §Chronic Pain Rehabilitation Program, James ¶ psychology across stakeholder groups, and global A. Haley Veterans’ Hospital, Tampa, Florida; Institute support for a national initiative to increase pain train- on Development & Disability, IDD Division of ing and competency in U.S. therapists. Among dir- Psychology, Oregon Health & Science University; ectors of graduate and postgraduate psychology kPain Research, Informatics, Multi-Morbidities and training programs, we found unanimous interest for Education (PRIME) Center, VA Connecticut a no-cost pain psychology curriculum that could be Healthcare System, Departments of Psychiatry, integrated into existing programs. Primary barriers Neurology and Psychology, Yale University, West to pain psychology include lack of a system to iden- Haven, CT, USA tify qualified therapists, paucity of therapists with pain training, limited awareness of the psychological Correspondence to: Beth D. Darnall, PhD, Stanford treatment modality, and poor insurance coverage. University, Systems Neuroscience and Pain Lab, 1070 Arastradero Road, Ste. 200, MC5596, Palo Alto, CA Conclusions. This report calls for transformation 94304. E-mail: [email protected]. within psychology predoctoral and postdoctoral a education and training and psychology continuing AAPM Psychology Task Force Co-Chair education to include and emphasize pain and pain bAAPM Pain Psychology Task Force Member management. A system for certification is needed to facilitate quality control and appropriate reim- Funding sources: This study was supported with fund- bursement. There is a need for systems to facilitate ing from the National Institutes of Health: NIH P01 identification and access to practicing psycholo- AT006651-S1 (BDD, SCM); NIH K24 DA029262 (SCM). gists and therapists skilled in the treatment of pain. Conflicts of interest: All authors report no conflicts of Key Words. Pain Management; Psychology; interest. Chronic Pain; Pain Training Programs; Education Abstract Introduction Objective. The Institute of Medicine and the draft In 2011, the Institute of Medicine (IOM) Report: Relieving National Pain Strategy recently called for better Pain in America identified that roughly 100 million training for health care clinicians. This was the first American adults live with ongoing pain [1]. Owing to its high-level needs assessment for pain psychology pervasiveness and negative impacts on society, pain services and resources in the United States. has been called a public health crisis. Often, chronic VC 2016 American Academy of Pain Medicine. 250 This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs licence (http://creativecommons. org/licenses/by-nc-nd/4.0/), which permits non-commercial reproduction and distribution of the work, in any medium, provided the original work is not altered or transformed in any way, and that the work properly cited. For commercial re-use, please contact [email protected] Pain Psychology Global Needs Assessment pain erodes quality of life for those living with the condi- therapists more generally. Degreed and practicing tion, as well as their families and loved ones. The finan- psychologists and therapists who have little or no pain cial impacts of pain are immense, with up to $635 education may be unlikely to return to graduate or billion annually attributed to medical costs and lost postgraduate training to receive such training, thereby productivity in the United States [1]. highlighting a need for nonmatriculate solutions. The IOM report called for university training programs in the In 1973, the International Association for the Study of health care professions to include standardized informa- Pain (IASP) defined pain as an experience comprised of tion about pain. Accordingly, we recognize a need to sensory and emotional dimensions [2], thereby establish- better integrate basic pain education into psychology ing psychology as integral to the experience of both programs at the undergraduate, graduate, and post- acute and chronic pain. Furthermore, a substantial body graduate levels. Such education would not confer learn- of literature has demonstrated that psychosocial factors ers with pain specialization status, but would provide are strong predictors of response to medical interven- essential core knowledge and possibly foster interest in tions, including surgeries and injections directed toward continuing education on the topic or even pursuit of pain relief [3,4]. Moreover, psychosocial factors are also formalized postdoctoral training. strong predictors of pain, function, and quality of life among people with chronic pain [5–17]. The biopsycho- In 2015, the Board of Directors of the American social model has emerged as the most comprehensive Academy of Pain Medicine (AAPM) established the model in the field of pain management [18]. Despite this, AAPM Pain Psychology Task Force. As a first step to- acute and chronic pain are often treated from a purely ward addressing the recommendations in the IOM re- biomedical approach [19], with psychological factors left port and the draft National Pain Strategy, the task unidentified, unaddressed, or inadequately treated. force sought to conduct a broad needs assessment for pain psychology services, resources, and training The biomedical approach is most often applied to people across key stakeholder constituencies across the with acute and chronic pain, and a body of research has United States. The national assessment involved de- identified pain education gaps and needs for medical stu- veloping and distributing tailored surveys to community dent training. For instance, survey research published in psychologists and therapists, to referring providers 2011 revealed that for many U.S. medical schools, the (e.g., pain physicians, primary care physicians/phys- curricula did not include any dedicated pain courses, and ician assistants, and nurse practitioners), and to the many other schools committed fewer than 5 hours to national community of individuals with chronic pain. pain education over 4 years of medical training [20]. Finally, we included in our assessment a survey of dir- Other survey research revealed that after completing resi- ectors of graduate and postgraduate psychology train- dency, roughly one-third of physicians felt “somewhat un- ing programs in the United States to broadly quantify prepared” or “very unprepared” to treat pain [21]. hours of pain content included in formal curricula and Similarly, there are broad limitations in the general psy- to determine potential interest in a pain psychology chotherapeutic community regarding how best to man- curriculum that could be integrated into their current age reported pain. Psychologists and therapists who do psychology program. not identify as pain specialists may experience discomfort in addressing pain concerns in their clients due to lack of Our national needs assessment had several goals. pain training and may actually do more harm than good Currently, psychologists and therapists in the United by making recommendations such as rest for chronic States are treating individuals with acute and chronic pain. For psychologists and mental health therapists, we pain regardless of whether they have any formal training found no such actual research, whether formal or infor- in pain. One basic goal was to conduct the first national mal, to quantify pain education, perceived competency, survey to describe therapist level of training, perceptions and therapist comfort in treating clients’ pain. of expertise, and comfort in addressing pain within the therapeutic context. We also aimed to understand inter- The IOM’s call for a “cultural transformation in pain pre- est in continuing education in the psychological treat- vention, care, education and research” includes the crit- ment of people with pain. For instance, low comfort in ical need for increased education and training for treating pain coupled with high interest in pain educa- cross-disciplinary health providers who treat individuals tion would signal value in developing and offering spe- with pain, including psychologists [1]. The draft National cific continuing
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