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.

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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 in that they are reflective as they develop their craft. of an institution’s local dynamics and resources, There is little exposure of these relatively psychologists and physicians are likely to play discrete professional cultures to one another in predominant roles in determining their develop- training, and psychology is clearly a minority ment. It is therefore worth considering cultural subculture within the medical majority culture. similarities and differences between psycholo- Whereas most health professions are trained as gists and physicians. At first glance, psycholo- dependent practitioners to physicians or trained gists and physicians appear to have much in to roles clearly defined within the medical sys- common. Particularly when viewed from the tem (e.g., advanced practice nurses, dentists, perspective of lay persons, both psychologists podiatrists), even psychologists specializing in and physicians occupy the polar end of a con- clinical health psychology typically only work tinuum in society, united by their unusual de- with physicians late in their training, in selected gree of expertise, authority on clinical issues, advanced practicum or internship placements. and professional power. Their clinical authority Similarly, physician trainees’ contact with li- imparts a unique autonomy and relieves both censed psychologists may be highly circum- groups of the burden of honoring alternative scribed, with contact limited to psychiatry rota- rules and alternative cultures to their own. They tions or selected “psycho-social” topics, such as share an emphasis on science and empiricism patient-centered communication. With physi- relative to other professional disciplines, in cians greatly outnumbering psychologists in which scientific questions are investigated inde- the health care system (at the authors’ facility pendently of sociocultural factors, which are either controlled or ignored. Both disciplines the ratio is 18:1), such limited exposure to value reductionism and study of variables, psychologists likely relegates the discipline rather than holism that may be more commonly of psychology as another ambiguous allied the focus of study in disciplines such as sociol- health profession. Even outside of the work- ogy or anthropology. place, all psychologists have personally experi- Despite these similarities, psychologists and enced medical providers, yet most physicians physicians are trained quite differently (Kings- (and their subordinates) have not seen a psy- bury, 1987). Medicine perceives science as a chologist professionally. matter of objective fact, uncovered by correct Given these contrasts, physicians and psy- and thorough investigation, whose unique con- chologists have good reason for not understand- clusion identifies a singular pathogenesis and ing one another. It may be a bigger challenge, thereby an indicated plan of treatment. Psychol- however, for either group to see themselves as ogy perceives science as a process by which essentially ethnocentric. Although psycholo- theoretical relationships among ideas are tested gists may be acquainted with the largely anthro- via their real-world measurable referents, in a pologic term, it is useful to unpack this complex continually evolving paradigm. Empirical vali- construct. Ethnocentrism is a process of evalu- dation is an ultimate test of clinical treatment ating other cultural groups based on the norms, strategies, but this feature is essentially practi- values, and beliefs of one’s own culture. This cal, and competing explanations for the clinical process typically happens without the sensitiv- problem are welcome to coexist. Psychology ity or awareness that one’s cultural “lens” arose as an academic discipline, awarding the creates a bias in how others are perceived. Cul- doctor of philosophy degree, identifying its turally encapsulated majority groups may be holders as scientist practitioners. The medical particularly at risk for ethnocentrism. These doctor title is a professional degree held by groups can maintain a stance of inherent supe- 118 FROHM AND BEEHLER riority because they lack the understanding that Specific Sociocultural Factors That Broadly their own culture-bound worldview is one of Influence the Health Care System: “Physics several perspectives rather than a universal Envy,” Stigma of Psychopathology, and norm. The end result of ethnocentrism is cul- False Alarms tural incompetence, manifesting in prejudice, dysfunctional relational patterns, or outright The treatment of chronic pain and the prac- dismissal of a minority group’s legitimacy. tice of psychology in the health care system also The ultimate responsibility and authority at- reflect some specific sociocultural issues that tributed to physicians, the relatively small por- have pervasive influence. Jefferson Fish (2000), tion of physicians’ universe occupied by psy- a clinical psychologist, articulated nicely the a chologists, and the lack of training in alternative concept of “physics envy,” whereby psycholo- worldviews easily explain any tendency for gists tend to struggle against a societal scale that physicians to be blind to their own ways of assigns ultimate prestige and credibility to relating to psychologists. However, the label of physics as the prototypically objective, physical ethnocentrism may be more ironic or surprising science, and minimal credibility to “soft” social to psychologists who have long claimed exper- sciences. Psychology aspires to be grouped with tise in human behavior and interpersonal inter- biology, seemingly as a way to be ranked actions, especially with a growing focus on top- among the “hard” natural or life sciences. Psy- ics such as discrimination and ethnic diversity chology is also likely to differentiate itself pos- (Fish, 2000). Consider that many psychologists itively from more qualitative social sciences, and physicians may do a relatively poor job in such as anthropology. In comparison to psy- understanding one another, and may be likely to chology, contemporary medicine is overtly evaluate one another’s professional practice linked to “hard” science in its conceptualization based on the ideals of their own discipline. For of disease as essentially biological, with treat- example, some physicians may discount the ment aimed at curing underlying pathophysiol- data from a consulting psychologist unless it ogy (Baer, Singer, & Susser, 1997). The issue of what is scientific and, therefore, credible is con- immediately impacts medical treatment, such as fused by varying definitions of science among the initiation or modification of opioids. At the these disciplines. Science is frequently identi- same time, psychologists may be quick to judge fied more by the subject of inquiry (such as a physician who disregards their contextualized universal biological mechanisms of disease) behavioral formulation in favor of relatively rather than as a method or process of inquiry simplistic input regarding a patient’s likelihood that could be applied to a multitude of topics. to misuse narcotics. In this scenario, a physician Thus, although the average clinical psychologist may be driven by their profession’s heavy em- is more highly trained in research methodology phasis on diagnostic precision, caution in pre- and statistics than the average bio-medically scribing a scheduled medication with high trained physician, our larger culture, our legal abuse potential, and the significant limitations system, our parents, and often psychologists of a 15-min patient encounter. In comparison, themselves tend to give more credulity to phy- psychologists working with more frequent, 50- sicians than psychologists as “scientific” (cf. min sessions may value an evolving case con- Weisberg et al., 2008, which demonstrates dis- ceptualization that will direct the application of tortion in favor of accepting scientific findings multiple patient-centered interventions. involving any neuroscience, even if terribly Whereas these well-engrained practice styles flawed, among all but the most sophisticated may serve their respective disciplines in isola- consumers). This bias based on perceived “sci- tion, the multidisciplinary chronic pain manage- entificness” influences the behavior of psychol- ment team is better served by psychologists who ogists seeking to influence the health care sys- are vigilant in applying a culturally informed tem and of the health care system in responding perspective to understanding their physician to leadership by psychologists. We suggest that colleagues that will enhance their ability to quality of life and functional improvement out- communicate and collaborate effectively for the comes of treatment, central to a biopsychosocial benefit of the patient and the medical system. understanding of pain management, are less SPECIAL SECTION: PSYCHOLOGISTS, CULTURE, AND CHRONIC PAIN PRACTICE 119 likely to compel system attention than would causative injury. In contrast, chronic pain is diminished postoperative complications or im- “managed” without expectation of eradicating proved lab values. pain completely, with top priority placed on The identity and behavior of psychologists disarming the psychological “alarm” reaction to appear further to have been modified by stig- pain and on optimizing functioning as self- matizing social responses to psychopathology dependently as possible as one lives concur- in Western culture. This stigma values biology rently with residual pain. However, the expec- over behavior and encourages a view of mental tations of many patients and medical providers impairments as voluntary, reflecting weakness regarding chronic pain seem to be heavily based of character, and/or shameful. Only recently in the acute pain model, notably including a was parity in third party payments for mental linear biomedical solution to a single biological health (as opposed to medical) treatment legis- cause. That is, we appear to have implicit con- lated by the U.S. Congress, and similar differ- fidence in technologic, physical interventions entials appear to exist through much of the for chronic pain with distant potential to be health care system in priority placed on mental curative (e.g., surgery) preferentially over bio- health program resources and respect paid to psychosocial, self-management based interven- mental health patients. Reflections of this soci- tions with stronger empirical evidence for their etal stigma can easily be seen within health care efficacy (Hoffman et al., 2007). Among pa- (Sartorius, 2002). We have observed that in tients, medical providers and health care system some sectors of the health care system, program decision-makers, there is great danger of titles have been changed from “mental health” misprioritizing medical-surgical approaches to “behavioral health,” presumably a less off- over biopsychosocial approaches for chronic putting and more holistic term, even though pain. Related to our developing discussion of “behavioral health” is easily confused with ad- system change, then, there is an inherent chal- jacent terms, for example, “behavioral medi- lenge for psychologists, as providers with non- cine.” Patients easily imagine that seeing a psy- medical credentials, to assume leadership in a chologist for a pain problem means “the pain is clinical area that seems to have physiologic in my head,” reflecting a larger cultural associ- bases but actually calls for rehabilitative, bio- ation (that a somatic concern meriting “psycho- psychosocial management. logical” attention is inherently imaginary or re- sulting from a controllable mental defect) and Cultural Competence and System Change sometimes reinforced by explicit or implicit in Health Care by Psychologists messages from their medical providers in making referrals to psychologists. Psychologists Within psychology, there is earnest and must naturally educate others regarding a bio- growing emphasis in cultural competence and psychosocial (vs. biomedical or psychopatho- diversity awareness. However, a likely hin- logical) understanding of chronic pain and may drance to progress in this area comes from psy- feel a need to dissociate themselves from psychology’s tendency to define culture as an at- chopathology to command credible leadership tribute of the individual. Psychologists are regarding pain management among patients and guided by group-based definitions of culture colleagues. and identification of cultural variables rather A third factor that psychologists must con- than seeing culture as a process that transcends sider when addressing how chronic pain is con- group membership (Lakes, Lopez, & Garro, ceptualized and managed within the health care 2006). Psychologists identify sources of cultural system is possibly unique to chronic pain as a variability based on racial, ethnic, or other so- chronic illness. If acute pain is an emergency ciodemographic groupings (Cohen, 2009), and signal, activating multisystemic alarms to mo- much of the energy in the discipline toward tivate the organism to curtail or prevent further multicultural competence has been geared to- tissue damage, chronic pain is a false alarm and ward knowledge and understanding of specific a nuisance discomfort that misleads its sufferers group and person variables. Emphasis on the into avoidant actions that can be dysfunctional study of these variables, typically via nomo- in the long run. Treatment goals for acute pain thetic techniques, accords with a focus on indi- are aggressive symptom relief and repair of the viduals and families as loci of intervention, in 120 FROHM AND BEEHLER clinical relationships that follow empirically de- within health care by emphasizing the value of rived rules. Unfortunately, this group-based fo- our unique skills (e.g., assessment), with some cus becomes less useful when we consider that proponents advocating acquisition of new skills not only do individuals simultaneously belong of obvious value in the existing system (e.g., to multiple groups, but that these considerably prescription privileges). Redefinition of our heterogeneous groups do not lend themselves value in terms intrinsic to the dominant culture well to developing typologies. In contrast, an- of the health care system is foreign to many thropologic definitions tend to consider culture psychologists. It may be challenging for psy- broadly as a people’s “way of life,” comprising chologists to accept and define a place within language, symbols, rules, and behaviors trans- the relatively structured social-professional hi- mitted over time (McElroy & Townsend, 1996). erarchy of medicine, to compete with physi- Culture has also been defined as “transactions cians to demonstrate value in health care, and/or between a set of shared values, practices, and to tolerate relatively patriarchal (vs. patient- traditions” (Tseng et al., 2002. p. 418) framing centered) values still common to many sectors culture as a dynamic social process. We endorse of health care. Further, the skills, leadership, a definition that may be particularly apt for and perspective brought by psychologists to the change agents, regarding culture as “what is at health care system are often highly effective but stake in local worlds,” or the social interactions invisible. Psychologists may compel power and of meaning and value in people’s everyday recognition through visible channels open to lived experience (Kleinman, 1995; Lakes, anyone in the system (e.g., research grants, Lopez, & Garro, 2006). These process-based advancement to managerial posts) which tran- variations on the definition of culture share the scend discipline and minimally require compe- implication that cultural competence results tence in local culture for their authority. Other- from an interactive social process and situa- wise, psychologists may achieve authority as tional awareness of cultural realities as opposed clinical experts if that expertise is recognizable to the cataloguing of knowledge on an infinite to the dominant medical culture, but instead, our number of predictive person variables. Shifting contributions often come via humble supporting psychologists’ mindset in conceptualizing cul- or facilitating roles, for example, advising phy- ture may enable us to function as health care sician leaders. Analytic or facilitative activity is system activists by seeing the system as client. entirely consistent with our identity and skills as From this perspective, system change begins as psychologists, and skills in empathy, communi- a process of discerning precise cultural dynam- cation, and formulation around interpersonal ics, then influencing the system strategically via dynamics should be a strong suit for psycholo- immersion in its culture, often in nonlinear fash- gists. However, we may be ambivalent about ion, without losing one’s bearings and identity contributing value through “supporting” versus as a psychologist. “leading” roles, and psychologist activists often Psychologists have an uncertain foundation struggle with whether they can be satisfied ef- from which to embrace this culturally sensitive fecting system change from a largely subordi- relationship to the health care system. We have nate position. Elaborated by practical skills, intrinsic value to the health care system, but as such as running meetings, understanding system we tend to be culturally incompetent regarding rules, procedures and priorities, and ability to that system, we emphasize the wrong assets. interact credibly in terms of the dominant med- Other disciplines (notably social work as a clinical culture, psychologists can be valuable and ical discipline) are trained to identify as agents effective agents of health care system change. of systemic change (Wax, 1968). Although there is brief attention to psychologists’ compe- General Notions on the Process of tence in outcome evaluation in accrediting stan- System Change dards for training programs (American Psycho- logical Association, 2007), graduate training of A lack of in-depth exposure to systems theory psychologists has not consistently emphasized or systems thinking literature may leave psy- program development, program evaluation, sys- chologists involved in chronic pain program tems theory, and/or medical culture compe- development feeling ill-prepared to apply this tency. Psychology has tended to market itself perspective to their local medical settings. We SPECIAL SECTION: PSYCHOLOGISTS, CULTURE, AND CHRONIC PAIN PRACTICE 121 have found that some of the more accessible Although we have briefly summarized a few literature on the topic comes from community formal works addressing key aspects of systems psychology, a subdiscipline with a long history change that we find particularly relevant for of adopting a systems perspective and strong psychologists as change agents, the remainder commitment to social change. Our goal in in- of our discussion is based on our firsthand ac- troducing this discussion is primarily to suggest count as psychologists in chronic pain and med- that adopting a systems perspective—not nec- ical practice. We offer a dichotomy of system essarily mastery of the systems literature—is of change strategies: (a) explicit, top-down, initia- foremost value for psychologists acting as tives endorsed by system leaders, with con- change agents. This shift to a systems perspec- scious cooperation by system targets for tive can reveal the interrelated cultural pro- change, motivated by clear incentives, and (b) cesses and subsystems that characterize most induced, gradual, incremental change that may medical settings that are easily missed if one is be strategically planned but is accomplished guided solely by traditional conceptual models without top-down mandates or incentives and in psychology that emphasize linear, unidirec- likely involves accommodation by the current tional processes (Foster-Fishman & Behrens, culture. The former is the typical form of orga- 2007). Engaging multiple stakeholders to iden- nizational change assumed by persons in tify and describe adaptive and dysfunctional charge, responsible for directing the system, system components is necessary to uncover who control the means to motivate and enforce both the “deep” (values, norms, beliefs, and initiatives and are accountable for outcomes. assumptions) and “apparent” (policies, proce- Such changes are not always culture-congruent, dures, resources, and power dynamics) struc- though their success is correlated with culture tures that underpin how health care for chronic congruence. Pay-based performance measures pain is conceived and managed (Foster- are a typical example of a seemingly effective Fishman, Nowell, & Yang, 2007). Identification means by which health care organizations in- of these cultural attributes can be facilitated by centivize system changes of highest priority in psychologists acting as participant-observers the organization’s mission. In accord with much conducting key informant interviews (Schensul, of our earlier discussion, such top-down pro- 2007), developing graphic displays of system cesses are not the clear norm in the domain of processes (Foster-Fishman, Nowell, & Yang, chronic pain management programming, as is- 2007), and constructing timelines of precursors sues are difficult to measure, of uncertain im- and consequences of systemic problems (Kre- portance to health care organizations, and/or ger, Brindis, Manuel, & Sassoubre, 2007). without consensus on desired solutions. These approaches can be used by change agents In contrast and in our experience, pain man- to develop contextualized depictions of systems agement systems improvements have frequently process that uncover root causes of system dys- depended on more grassroots activism by citi- function. Intervention for root causes may only zens of the health care system motivated by an require enhancement of current operations (first intrinsic investment in pain-related issues, with- order change), but enduring change often re- out supporting organizational mandate. Under quires a paradigm shift in how the problem is these conditions, we suggest that successful sys- conceptualized (second order change). If, for tem change can further be seen in terms of two example, psychologists have unknowingly as- contrasting but additive processes. First, orga- sumed a marginalized role in the chronic pain nizational change is potentiated by persistent management team, then second order change effort on the part of activists, to raise issues to would target adoption of a biopsychosocial stake-holders and leaders in understandable model for understanding and treating chronic terms, educate them about implications, present pain. Keeping in mind that systems change data on options and consequences, and ensure hinges largely on social change (Tseng et al., that communication is optimized among neces- 2002), reconceptualizing the management of sary agents of change. Especially in underre- chronic pain will likely mean altering the status sourced systems, such activism rarely competes quo by modifying well-entrenched social pat- successfully for attention and resources against terns among psychologists, physicians, and ad- familiar and prioritized issues that have been ministrators. associated with tangible consequences for deci- 122 FROHM AND BEEHLER sion-makers and stake-holders. For example, trumps love” in organizations, meaning that ex- overwhelmed primary care providers would be penditure of resources is far more easily justi- foolish to take time away from addressing sys- fied to avert a crisis than to realize an ideal (e.g., tem-mandated clinical issues on which pay in- higher quality service) in the absence of crisis. centives and administrative sanctions depend, to Even egregious circumstances often become fa- honor new initiatives in education or functional miliar and normative under conditions in which reassessment of a patient with chronic pain, for participants have no control over their aversive- which there are no such performance incentives. ness and have either good reason to persist or are Under these conditions, behavior change can aware of no other option (i.e., learned helpless- only be accomplished (if at all) by repeated ness). Saul Alinsky, a successful community or- iterations of timely, relevant information, pre- ganizer in civil rights campaigns of the 1960s sented in terms recognizable and important to commented (Alinsky, 1971, pp. xxi-xxii) that in- the dominant culture (e.g., cost off-sets), with dividuals do not easily abandon familiar experi- consequences that shape behavior gradually and ence for something new. A revolutionary must consistently in the desired direction and/or foster discontent and instill enough questioning of transmitted via credible models for desirable current values to potentiate a willingness or even a practice. Often such initiatives become multi- passion for change. Reformation occurs when year campaigns, in which information is re- masses of people are disillusioned or hopeless peated or updated, building awareness and fa- about the existing system, whether or not they miliarity within the culture of the organization, have a specific alternative in mind. accumulating small incremental steps or build- Creating incentives to give up the status quo ing foundations for eventual endorsement by is critical. A competent activist says to organi- the culture at large. This slow, incremental pro- zational leaders “We’re at risk. It’s not work- cess demands vision and patience and is some- ing.” to trigger their anxiety and investment in a times likened to geologic time, suggesting a solution. It is frequently also necessary to com- slow, steady pace as well as a promise of even- municate “we cannot solve this problem,” to tual, gradual movement. recruit uninvolved agents of the system who Second, there are opportunities to catalyze control solutions, rather than reassuring leaders accelerated change. In reality, geologic history that the problem may be solvable under existing is more accurately viewed as long periods of circumstances. inertia, punctuated by energizing events, for example, volcanic eruptions, earthquakes, and so forth, that yield great change. Similarly, ef- Practical Recommendations for fective organizational activism often depends Psychologists as Health Care System on perceptive creation and/or exploitation of Activists transient opportunities for accelerated change that shift the terms or create new incentives We offer the following strategic and practical within the organizational culture. The Joint recommendations for psychologists as change Commission on the Accreditation of Health agents, which combine deduction from princi- Care Organizations (JCAHO) has recently ples discussed above with our own anecdotal placed significant emphasis on pain-related or- experience. These recommendations are ex- ganizational procedures (JCAHO, 2002). This pected to be particularly relevant within large external incentive has induced heightened col- health care organizations, such as the VA, but laboration across the health care system toward also for health care systems in general. improvements in pain management, often using • Become competent in the local norms of solutions prepared previously by grassroots ad- medical culture. Cultivate mentors within the vocates but never implemented, because of their medical culture. Learn local regulations, proce- cost. dures, resource issues, power dynamics, and It may be counterintuitive to psychologists politics that influence decisions and outcomes. that catalyzing change may depend on facilitat- Speak in the language of medical providers and ing distress to make disruption of the status quo build credibility in terms valued by the medical worthwhile. We have heard the adage that “fear culture, for example, tangible actions and rec- SPECIAL SECTION: PSYCHOLOGISTS, CULTURE, AND CHRONIC PAIN PRACTICE 123 ommendations, as opposed to theories. Be col- the change is not actively opposed by the sys- league-centered in formulating strategies. For tem and can be sustained through local effort, it example, in one clinic, providers are most re- can become accepted over time as normative, sponsive to informal education by joining them especially as staff turnover. Similarly, in the for lunch, whereas another clinic might prefer a absence of a clear physician authority or cham- formal presentation and hand-out. pion, chartering a group of collected local ex- • As stakeholders within the health care system perts (such as a Pain Management Committee) typically have different perceptions of system dy- can convey immediate authority to its formal namics, different definitions of the problem, dif- representatives and justify input to the organi- ferent priorities, and so forth, it is essential to not zational hierarchy on relevant issues. assume a single objective reality for system • Leading organizational change or com- dynamics and to involve all possible stakehold- mittees requires its own set of administrative ers in defining issues. Focus groups can be skills, which most aspirants learn along the extremely valuable in developing consensual way. Conscientiousness and diligence can views of problems and soliciting buy-in. For command respect and confidence early on, as example, a chronic pain clinic designed by spe- one is developing these skills. Form partner- cialists may be less successful in changing the ships with co-leaders who have complemen- culture of the organization and improving over- tary skills and knowledge bases, either as all pain management than a less ambitious opi- mentors or collaborators. In our experience, oid renewal clinic developed in concert with for example, collaborating nursing and per- primary care providers and other stakeholders to formance management colleagues have often meet their self-identified needs. strongly balanced psychologists’ knowledge • All else equal, a physician with limited or limitations in clinical logistics and adminis- incorrect knowledge will win most times in trative processes, respectively. refuting a knowledgeable and correct nonphy- • Ensure that you communicate objectives to sician in the eyes of health care or society. the bearers of power and resource necessary to Physician collaborators have difficulty main- achieve them and in a form that they can easily taining their loyalty to nonphysicians when understand. Appeal to organization leaders for challenged by other physicians. Stakeholders support in terms of value/cost to the organiza- must be able to hear from proponents with tion. We accomplished significant movement whom they can identify and who speak their toward local objectives only after appealing to language. Develop physician champions, ide- report to a hospital executive committee (that ally highly credible within the dominant culture, included necessary leaders), instead of a com- who will speak for change and visibly support mittee responsible for tracking organizational minority spokespersons when their voice is nec- performance data (whose members had no con- essary. Routinely keeping the Chief of Staff trol over policy). informed and seeking his or her advice in im- • Outcome data may be a universal language plementing strategies are obvious and essential if they speak in terms that are understood and examples. valued. Producing outcome data typically re- • Especially in trying to evoke gradual cul- quires recruitment of expertise and labor re- tural change without solid top-down endorse- sources that can be difficult to come by and ment, sweeping system-wide change rarely whose costs need to be considered as part of works, in our experience. Work first with staff strategic planning. Our facility’s central pain- most likely to buy in to proposed changes, or related performance improvement outcome data the “early adopters.” Ensure successful out- are collected via laborious chart audits, primar- comes in one sector and then offer them for ily through the voluntary commitment of Pain export. A certain minority of staff will never Resource Nurses. This resource allows us to use embrace a given change, but they do not have to more clinician-friendly means of electronic pain keep the rest of the system from responding. management documentation that improve staff • In the absence of valuation for a system compliance, but at significant cost that the fa- change, such as an unfunded clinical program, if cility may not always be able to afford. 124 FROHM AND BEEHLER

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Correction to Erbes, Curry, and Leskela (2009)

In the original online verson of the article “Treatment Presentation and Adherence of Iraq/Afghanistan Era Veterans in Outpatient Care for Posttraumatic Stress Disorder,” by Christopher Erbes, Kyle Curry, and Jennie Leskela, (Psychological Services, 2009 Vol. 6, No. 3, 175-183), the copyright for the article was listed incorrectly. This article is in the Public Domain. The online version has been corrected.

DOI: 10.1037/a0020165