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Psychologists As Change Agents in Chronic Pain Management Practice: Cultural Competence in the Health Care System

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Psychologists As Change Agents in Chronic Pain Management Practice: Cultural Competence in the Health Care System Psychological Services In the public domain 2010, Vol. 7, No. 3, 115–125 DOI: 10.1037/a0019642 Psychologists as Change Agents in Chronic Pain Management Practice: Cultural Competence in the Health Care System Karl D. Frohm Gregory P. Beehler VA Western New York Healthcare System, VA VISN 2 Center for Integrated Healthcare, Buffalo, NY Buffalo, NY Psychologists bring great value to health care systems, but our ethnocentrism regarding the medical community often limits our effectiveness as agents of change. Based on experience in developing pain management services within the Department of Veterans Affairs health care system, we discuss cultural issues as central to effective systems change and provide specific recommendations for psychologists aspiring to change organized health care systems, such as the Department of Veterans Affairs. Consideration is given to the misfit of the biomedical model to chronic pain, “physics envy” affecting the authority accorded psychology, and societal stigmatization of psychopathology. A process-based definition of cultural competence is recommended as improving on psychology’s intrinsic group-based notion of culture in engaging the medical community. The systems thinking literature is sampled in summarizing practical recommendations that include identifying features of local medical culture and power dynamics between psychology and medicine that can be modified by engaging stakeholders in an interpersonally effective manner. Keywords: pain, psychologists, organizational culture, cultural competence Chronic pain is associated with a problematic endeavors of psychologists to transform health set of issues for the health care system and care systems, based closely on our direct experi- society. In particular, best practice standards in ences in pain management within the Department chronic pain management centrally emphasize of Veterans Affairs (VA) health care system. biopsychosocial formulation, a paradigm that is Chronic pain management as a focus for system only partially embraced currently in health care. change serves as a prototype for other biopsycho- Psychologists play a central role in chronic pain social medical issues and also bears its own management but do not do so easily. While unique features. We suggest the adoption of sys- some leading psychologists have contributed tems approaches to change, emphasizing themes valuably to understanding and early adoption of of culture, cultural competency and ethnocentrism this paradigm and others in general may apply a in attempting to more effectively facilitate health systems perspective in their clinical practice, care system improvements. We relate these ideas most rank and file psychologists have missed to established theoretical paradigms, such as sys- opportunities to facilitate system change in this tems change, but we do not comprehensively re- and similar areas of health care. We purport that view this literature, as previous authors have pro- this failure reflects our lack of training as vided excellent comprehensive discussions of change agents, lack of identification with the these issues (Checkland, 1984; Midgley, 2000). larger health care system, and faulty definitions Our intent is to expand thinking regarding health of culture within the discipline of psychology. care culture and leadership by psychologists, and This paper applies a systems perspective in- to offer practical implications for system change. formed by anthropologic notions of culture to the Health Care and Societal Responses to Karl D. Frohm, VA Western New York Healthcare Sys- Chronic Pain: A Challenge to the tem, Buffalo, NY; Gregory P. Beehler, VA VISN 2 Center Biomedical Model for Integrated Healthcare, Buffalo, NY. Correspondence concerning this article should be ad- dressed to Karl D. Frohm, Lead Psychologist, VA Western Several factors make the development of pro- New York Healthcare System, 3495 Bailey Ave (116B), grams and system improvements in chronic Buffalo, NY 14215. E-mail: [email protected] pain management inconsistent and difficult. 115 116 FROHM AND BEEHLER Chronic pain is commonly regarded by experts (Crowley-Matoka, Saha, Dobscha, & Burgess, as a biopsychosocial problem (Gatchel et al., 2009), and medical systems do not expect lead- 2007), and multidisciplinary treatment of ership by nonphysicians. As health care provid- chronic pain is the state of the art (Flor, Fydrich, ers tend to access new clinical and scientific & Turk, 1992). In particular, development of findings most closely associated with their pain treatment within the VAs health care sys- home disciplines, physicians may be unaware of tem is now formally conceived in terms of a developing paradigms for pain management biopsychosocial model and a stepped care struc- published in pain specialty and psychological tural approach to treatment resources (VHA journals. Physicians often identify anesthesiol- Directive, 2009-053, Pain Management; Veter- ogy as the authoritative specialty in chronic ans Healthcare Administration, 2009). Though pain, as anesthesiologists are most frequently the International Association for the Study of board-certified as medical pain specialists, Pain (IASP) offers recommendations regarding though anesthetic procedures play a relatively the development of multidisciplinary pain cen- circumscribed role in chronic pain management. ters (Cousins & Loeser, 1990), there is no single Conversely, VA clinical health psychologists standard for their staffing or treatment philoso- are typically employed by mental health clinical phy. Chronic pain management programs have systems, whose core mission often does not tended to be developed by local champions with include pain management. structure and composition largely determined Pain is essentially invisible as a symptom, by available interest, resources and expertise, as and the complex biopsychosocial impact and opposed to any industry standard or even local maintenance of chronic pain defy understanding organizational mandates for what a chronic pain within a conventional biomedical disease treatment structure should look like. Therefore, model. General lack of understanding of individual programs have tended to vary widely chronic pain as a disease entity contributes to its in compositions and treatment models. For ex- stigmatization in society and in health care, ample, across facilities in the authors’ VA even to the point that services for treating health care network, specialty pain clinics are chronic pain appear to have been de-valued. led by physiatry, anesthesia, family medicine, Chronic pain has often been regarded within the and palliative care specialists, ranging from sin- health care system as a nuisance medical prob- gle provider to multidisciplinary staffs. Conse- lem, not quite elevated to the level of recogni- quently, even during the current evolution of tion as a legitimate disease, and at worst as a excellent clinical practice guidelines and for- symptom cluster representing somatized psy- ward-looking models for treatment in this com- chopathology, drug dependence, or antisocial plex clinical territory, there still is no single behavior in search of disability funding. Mis- standard model for chronic pain treatment pro- treatment because of these skewed characteriza- grams. In turn, outcome assessment and the tions is especially damaging, as patients with empirical study of pain treatment are difficult, as existing pain treatment programs defy valid chronic pain tend to be high users of health care comparison to one another. system resources (Phillips et al., 2008). Patients The question of how to structure a chronic with chronic pain can be managed effectively, typically through an interdisciplinary, collabo- pain management program is further compli- 1 cated because no medical specialty “owns” rative self-care model of treatment that consid- leadership in chronic pain management. As ers chronic pain to be a lifelong biopsychosocial there is good empiric evidence of the centrality disease entity. However, there is little evidence of psychosocial factors (Geisser, 2004) and ef- of health care systems prioritizing improvement ficacy of psychological interventions (Hoffman, of treatment programs for chronic pain. The Papas, Chatkoff, & Kerns, 2007) for chronic National Pain Care Policy Act, which mandates pain, it should not be surprising that psycholo- widespread investments in the study and treat- gists often contribute to clinical research and ment of pain, was introduced in multiple ses- treatment program leadership in chronic pain. However, American medicine has generally op- 1 As noted by Anthony Mariano in the VISN 20 Chronic erated from a biomedical, rather than biopsy- Pain Education Course, accessible to VA users at http:// chosocial, model in the treatment of pain vhapugweb3/pain/ChronicPain/index.html. SPECIAL SECTION: PSYCHOLOGISTS, CULTURE, AND CHRONIC PAIN PRACTICE 117 sions of congress, passed the House of Repre- clinicians inferred by society as scientific. Phy- sentatives in 2009, but awaits resolution of mul- sicians are first decision makers and gradually tiple House and Senate versions as this paper is add depth and breadth to their familiarity with being submitted. clinical concerns as they gather experience. Psychologists are first scholars, often seeing Psychology, Medicine, and Ethnocentrism very few patients and spending comparable time in supervision early in their training, and Although chronic pain programs are neces- gradually becoming more efficient and decisive sarily heterogeneous
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