Response to a Petition Against the NICE guidelines

Okay so I’m going to acknowledge that this blog post might be a little divisive. But if I look around at our society right now, most issues regarding health are. This is probably more of an opinion piece than many of my posts, which I do research (yes, I read scientific journal articles to make sure I get the facts as straight as possible for all of you). I did a post (and a podcast episode) about the guidelines that came from NICE in the UK regarding the treatment of chronic pain awhile back. These guidelines were controversial within the medical community itself because, well, they recommend against the use of pain medications due to a lack of evidence that they are effective AND that many of them can be addictive. Doctors, of course, like to prescribe medications.

The recommendations for the treatment were: (1) exercise, (2) acupuncture, (3) cognitive behavioural therapy, (4) acceptance and commitment therapy, and (5) anti-depressants. I recently saw a post on Instagram that linked a petition against these guidelines. The reasoning behind the petition was that it makes it harder for people to get the treatment (i.e., medications) that they need to manage their chronic pain. Much like doctors, most patients also feel like medications are the way to go (which is a fairly western version of pain management – check out the podcast episode with Dr. Richard Harris for an East meets West version of pain management that tends to work better). Now, I’m not saying that pain medication doesn’t work for anyone ever. And I don’t think that’s what they guidelines are saying either. They are saying that the evidence-base isn’t strong for most of those medications, but it is strong for these alternative treatments. The other argument in the petition is that the alternative treatments are expensive and not covered by insurance. I’m going to break each of these arguments down a bit further.

Me during a hike this summer.

So first, whether or not people will still be able to access pain medications. Regardless of these guidelines I find it very hard to believe that most Western doctors will stop prescribing pain medications. Like I mentioned earlier, most doctors were upset by the guidelines in the first place. Also, doctors are trained to prescribe medications, they aren’t trained (literally almost no training) on prescribing alternative treatments. It’s more than likely they’ll go with what they know. They might though be more willing to recommend alternatives as adjunct treatments. This is actually what my rheumatologist did. She recommended that in addition to the medications she prescribed, I seek out alternative treatments such as physiotherapy and naturopathy (and I did and they were helpful). I get why people are upset about the guidelines, especially if they mostly rely on medications. The guidelines do state that for some conditions (mostly CRPS) pain medications do work best (it’s best just to read all the guidelines – AND all the hyperlinks that give fuller explanations yourself – available here).

The second point that alternative treatments are expensive, is true and not true at the same time. Exercise is technically free. I exercise at home – both cardio (walking) and strength training (body weight) and have spent $0 on it since the pandemic started (I did go to the gym before that). But a lot of people with chronic pain are hesitant about exercising (check out the podcast episode with Dr. Frank Nahn). Acupuncture can be a bit pricey depending on where you live, but it is sometimes covered by insurance. I had insurance through work that covered my naturopath, who did acupuncture, for up to $500 a year. That’s about 6 sessions. I’m not saying it’s always covered, but it might be. CBT and ACT, the two psychotherapies listed are along the same lines as acupuncture. They might be covered or they might not be. In the province (Canada) that I live, it is covered up to a certain amount by provincial insurance, or short-term therapy is also covered by the provincial government. There are also self-help versions of these available at bookstores and online. Finally, anti-depressants, again may be covered by extended health insurance if you have that. Also, wouldn’t a better petition to be to try and get governments (or insurance companies) to cover these services for chronic pain and chronic illness patients? Just a suggestion…

As a therapist who went into the field to help people with chronic pain and illness (and their co-occurring mental health issues I decided to primarily use ACT with my clients due to its large evidence base).

I guess what I’m saying is that if you dislike the guidelines because you only rely on medication but also haven’t tried or even looked into these alternatives, then it makes sense that you’d be upset. I would be too! I started using some of these alternatives (exercise, acupuncture, CBT/ACT) long before these guidelines came out and I saw how much they improved my well-being, well over and beyond what my medication has ever done. I also find it interesting that I often see posted online people complaining that their medications aren’t really helping. It’s easy to have some cognitive dissonance here. We want to believe medications will solve all our problems even when we’re acknowledging that they’re not. I’m doubtful that I’ll change too many minds with this post, but my hope is that we at least get thinking about using both holistic approaches (like in NICE’s guidelines) and are medication together so that we can get the best results.

Okay, that is all for this week. Keep making the most of it everyone!

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The Body-Mind Connection

There is such a delicate balance between the body and mind and how they interact with each other. At the core, our mind… or more specifically our brain, controls everything from our thoughts and feelings to our pain levels to basic functions such as breathing. It sends the signals to all the body parts. Our bodies can also let our brains know when we’ve been injured for example. But what happens when there is too strong an influence of one over the other? This often happens in chronic pain, when the pain signals are amplified much more than they should be. Another common problem is the influence of our mental health on our chronic pain. For example, if you have higher anxiety or depression, you might notice that you have higher chronic pain as well. This is part of why I’m specializing in chronic illness as a psychotherapist. The balance is delicate and all parts of health need to be looked after in order for us all to live our best lives.

Let’s look at fibromyalgia as an example, because it is a fairly common chronic pain condition. According to medical research, depression and pain share receptors in the brain. So it’s common for people with fibromyalgia to develop depression (less common the other way around but still possible).Dr. Ananya Mandel (news-medical.net) So treating depression and chronic pain at the same time can be beneficial. A number of antidepressants have found to be in treating both. If you think you’re already on a lot of medication and don’t want to take anymore, then therapy for depression, may also impact chronic pain, especially if you’re clear with the therapist that you’re looking to treat both simultaneously. An even more interesting example is anxiety, which often feeds chronic pain, making it feel worse. Anxiety can increase how sensitive we are to pain, and therefore make the pain worse than it would be without anxiety. Dr. Ananya Mandel (news-medical.net) That being said, having pain can lead to anxiety, and so it is a vicious cycle. In this case, it might be more beneficial to treat the anxiety rather than the pain. As anxiety decreases, pain should decrease as well. Whether it’s pharmacological interventions, or psychotherapeutic ones (though for anxiety best results are always a combination of the two), if you have a lot of anxiety and a lot of chronic pain, it might be time to get a referral to a mental health professional!

I have a diagnosis of fibromyalgia (along with UCTD) and I used to have anxiety. While I do still have chronic pain, it is much less intense than when my anxiety was bad.

Let’s quickly talk about stigma, because while it’s decreasing, I want to recognize that some people still struggle with it. You are not crazy if you seek out mental health help. You’re not abnormal. A lot of things people tell me are normal, or do make sense given their circumstances. Mental health help is not just for the severely ill, it’s for everyone, because everyone struggles. If it’s a family member that is playing into the stigmatization for you, get them to read this post, or heck the millions of other posts and articles out there on mental health and stigma, and who is seeking services for what. And if that doesn’t help, remember that you have to do what’s best for you, not for other people.

If you have more questions about the body-mind connection, I am going to be doing a podcast episode on it in the near future, so feel free to email or DM me (on Instagram) some questions and I’ll answer them on air! Until then, keep making the most of it!

Chronically Living and how to make the most of it – new episodes every Monday!

Treating Depression

Depression is one of the most common mental health problems (right up there with anxiety). It also commonly co-occurs with chronic illnesses. If you’re feeling depressed, or have been diagnosed with Major Depressive Disorder, it’s really important you are treating it in some form. As a therapist-in-training, I see many clients with depression – some with both depression and anxiety, some with perinatal depression, some with depression and chronic illness – and there are a lot of evidence-based treatments out there. It’s really important to know that you don’t have to suffer alone. So I thought this week, we’d talk about some common treatments, and some up-and-coming ones for depression. I also have an entire podcast episode dedicated to depression and chronic illness this week, which you can access here.

This week’s podcast.

For chronic illness, depression most frequently occurs in people with Alzheimer’s, autoimmune diseases of all sorts, cancer, coronary heart disease, diabetes, epilepsy, HIV/AIDS, hypothyroidism, and Parkinson’s. I got into the criteria for major depressive disorder in the podcast episode, so definitely check that out for more information. When it comes to treating depression, the two most common routes are anti-depressant medications and psychotherapy. Anti-depressants most commonly come in the form of SSRIs (selective serotonin reuptake inhibitors) that alter our brain chemistry because it is implicated in depression (our brains are not the only thing that is implicated though). There is a lot of research that supports anti-depressants in treating depression, though research also shows that it works as well as a placebo. In other words, if you believe it will help it will. Now don’t get me wrong, I fully support someone taking medication (unless you’re pregnant or breast-feeding and can’t – thus why I see many perinatal moms in my practice), however what a lot of people find is that just taking medication isn’t enough to see significant improvements in their symptoms, and many people don’t want to rely on medication forever.

Depression affects about 20% of the population in their lifetime.

That’s where option 2 comes in: psychotherapy. As a student, I see about 10 clients a week plus I co-facilitate a group for 2 hours a week. There is a lot of research that supports the use of psychotherapy. My podcast episode on anxiety, which you can access here, breaks down how much your therapist and you each contribute to your outcomes in therapy, which is important to know. As for what type of therapy, there are many to choose from and they all have good outcomes. CBT (cognitive-behavioural therapy) and it’s third-wave counterparts (DBT, ACT, SFT, etc) are the most common. Typically this involves a combination of talk therapy, where you tell your therapist about your thoughts and feelings, and then the therapist giving you some things to try out in session that you can also practice between sessions (some people call it “homework” but I don’t like that term). Another option for therapy is psychodynamic, which involves talk therapy plus the therapist often makes interpretations. And then there are the therapies that rely mostly on talk, utilizing the therapeutic relationship, such as person-centred, existential, etc. All of these can help and are something I highly recommend. There is also evidence that different lengths of therapy are beneficial as well, from one session of drop-in counselling to short-term (10-20 sessions) of CBT or long-term (more than 20 sessions) of person-centred therapy.

Our thoughts and feelings can be like quicksand. Our natural tendency is to struggle, but that only makes us sink deeper in. The actual way to get out of real quick sand: be a still and flat as possible and let yourself float to the surface.

If you are in immediate crisis because of self-harm, abuse, trauma, and suicidal thoughts/plans, then please contact your local help line. I’ve put some numbers in the show notes for my podcast on depression. A quick Google search can help you find them in your country. If you don’t like talking on the phone, there are some organization that offer texting services. I volunteered for Kids Help Phone in Canada which had switched to primarily a texting hotline since many young people prefer to text. You are strong for reaching out because it is not easy to.

Canada.

In terms of other treatments, a few are available for treatment-resistant and severe depression. Electroconvulsive therapy (ECT), which used to be called “shock therapy” can be helpful for people with severe depression, though there are some potential harmful side effects, and psychiatrists don’t commonly use this unless necessary. Transcranial Magnetic Stimulation (TMS) is another option for treatment-resistant depression where magnetic pulses stimulate the nerves in your brain. Newly approved in Canada (and how I got the idea for this post) is the use of Ketamine for treatment-resistant depression. Ketamine is a dissociative drug that has a lot of research supporting its use for depression. It activates your glutamate, dopamine and serotonin receptors in your brain. It takes effect much quicker than anti-depressants and has shown to decrease suicidal ideation. So far research shows no long-term side-effects, though because it is a psychedelic drug, there is the chance of substance dependency.

Great video for anxiety and depression.

Whether or not you have chronic illness, if you have depression there is hope for recovery, and lots of options available. Talk to your GP, your psychiatrist, a psychotherapist or whomever else is or could be part of your mental health care team. That way, you can keep making the most of it.

Integrating Health with Mental Health

Recently I read an article in a psychotherapy magazine put out by the BCACC (British Columbia Association of Accredited Counsellors) about how therapists can and perhaps should integrate health promotion into their clinical practice. Being interested in health psychology anyway, and wanting to work with people with chronic illness as well as mental health problems, I devoured the article. Then I did a quick google search to see what others are saying. And while there are not a ton of journal articles on the subject, there are a few, all pointing to the same thought – this is something therapists should do. What makes it difficult is that psychotherapists, whether they hold a Masters or PhD (or not, depending on where you live they may not need either), typically don’t have a lot of training in health outside of mental health (always a little bit as it relates but rarely a large amount). This makes me curious as to what everything thinks about therapists encouraging health promotion, in some way, during counselling.

Article from Insights magazine (Spring 2017 issue)

What this article really looks at is not just physical health or mental health but all components of health. A holistic approach. Sometimes people go to therapy for things like weight loss, which in that case, health promotion and education seems necessary. Other times someone might bring it up as a secondary concern. There’s also, of course, the interrelation between things like exercise and nutrition and mental health. As well as sleep and mental health. See where I’m going with this? It actually might be almost impossible for therapists to not integrate health into counselling. So, while I usually save this kind of stuff for my premium blog, I thought I would share some health behaviours I’m going to put extra effort into this week, and I hope everyone reading thinks about some that they can as well! Body-mind connection week indeed!

  • nutrition: I’m going to go with making sure I eat fruit everyday (which I typically do but sometimes stumble on the weekends)
  • exercise: putting yoga back back into my routine at least 2x/week
  • sleep: ensuring I don’t have anything to drink after 8pm (part of sleep hygiene!)
  • other (social, hobbies, gratitude, mindfulness): playing the piano daily (I haven’t been playing as much as I would like)

As you can see, integrating health is rather inclusive and definitely extends beyond just physical aspects. Medication adherence can be another really important one for chronic illness warriors. The article I read speaks about Maslow’s hierarchy of needs, which I’ve mentioned in previous posts. We need to take care of our basic needs in order to take care of our higher needs. The three basic components of physical health I mentioned above are so important. So here’s my question (and I’d love answers in the comments), would you want your therapist to help you with aspects of health promotion that you are neglecting? Why or why not?

Family hike in the summer.

Until next week, keep on making the most of it!

Pain Scales – The Enemy of Chronic Pain Warriors

Literally my least favourite question when I go into any doctor or specialist appointment is, “what is your pain like today?” or “on a scale of 1 to 10, 10 being the worst ever, how’s your pain right now?” To someone with chronic pain, these are the most useless, arbitrary questions. Here’s the thing, I understand why doctors and other healthcare professionals ask the question. They want to get a gauge on if your pain is better or worse than it has been in the past. It totally makes sense. However, there are a few things about chronic pain (and pain in general) that aren’t taken into account with this questions.

  1. My perception of what a “10” is may be higher or lower than your perception of what that is.
  2. I’m not always entirely sure what number I should give. Like really, what is the difference between a “6” and a “7”?
  3. Often pain changes throughout the day, so just because I give it a “4” right now, doesn’t mean that it won’t be an “8” in half an hour.
Hm… I’m smiling and happy in both pictures and yet my pain is a “0” on the left, and a “7-8” on the right.

And yet, this is always the first question asked at any appointment. Sometimes I literally just want to say “I don’t know.!” How many of you feel this way to? Plus, sometimes there is this need to want to give a higher number so that the pain is taken more seriously and not just dismissed. Here’s the thing that healthcare professionals often miss – there are better ways to describe pain than using a 1-10 scale. For example, “what type of pain are you experiencing/do you experience?” “What times of day are worst for pain?” “What activities or circumstances do you notice more pain or less pain?” “Are there any points in the day when you feel little to no pain?” And so on. These questions are easier to answer, and honestly, give a more realistic perspective of my pain than me guessing at a number to give my doctor.

Just gonna throw in the random deer visiting a retirement home across the street from me.

The main model used in medicine (and psychology) right now is the biopsychosocial model (except sometimes doctors forget to use it when talking about chronic pain it seems). For those of you not familiar with this, it is the interplay between biological and psychosocial causes (or maintenance) of a medical (or psychological condition). When applying this model to chronic pain, we look at the biological causes of an illness or injury, and how psychosocial factors maintain or increase the physical sensations of pain. It’s that mind-body connection. Here’s an example: the hypothalamic-pituitary-adrenocortical (HPA) system in your brain has been associated with several chronic pain syndromes including fibromyalgia, chronic fatigue syndrome, rheumatoid arthritis, and MS. It is one of the biological causes of pain (though not necessarily the only). Psychological factors that can maintain or increase this pain include feelings of helplessness and hopelessness. Social factors and behaviours that maintain and increase pain include door diet and nutrition, lack of exercise, and substance use (including smoking). Stress is another major psychosocial factor associated with chronic pain. So, rather than asking what are pain is on a scale from 1-10, looking at these factors is likely more productive in both understanding and managing pain!

Image from: https://www.practicalpainmanagement.com/treatments/psychological/biopsychosocial-approach
The paragraph on the biopsychosocial model is cited from this article.

Let’s talk about pain management. Whether you do this on your own, or with the help of your healthcare team, here are some ways to improve your pain management (because let’s face it, chronic pain is unlikely to magically go away):

  • medication compliance – taking all medication as prescribed!
  • addressing psychological factors – such as anxiety – this could be through relaxation and meditative techniques or even exercise, or going to see a psychotherapist
  • utilizing interdisciplinary healthcare teams – do you have a family doctor? A specialist for your illness or injury? A psychotherapist? A physical and/or occupational therapist? Anyone else who can help you with your pain? (I also have a naturopath and chiropractor for example).
Make a therapist part of your healthcare team! We’re here to help!
(just noting that I’m a therapist-in-training right now)

For anyone reading this who is not a chronic pain warrior, please remember that pain isn’t in our heads, and telling us to just deal with it isn’t helpful. In fact it can be stigmatizing, and people with chronic pain always face stigma because of a lack of understanding. We may laugh, smile and have fun, and yet be in pain at the same time. The things are not mutually exclusive. I’m going to link a few episodes of my podcast that complement this post below. For now, keep making the most of it everyone!

Mental Health and Chronic Illness

The “I Suck” Feeling

Locating Our Inner Strength

How Stress and Anxiety Manifest in the Body

Holistic Approaches to Chronic Pain

How Do You React to New Symptoms and Side Effects?

What do you do when you have an expected new symptom? Or weird side effect from a drug or surgery? Or a better question, how do you feel, not just physically but also emotionally? It’s tough having a chronic illness. It’s tough starting a new medication or having a surgery. And so many chronic illnesses are invisible, so it’s difficult for others to understand exactly what is going on with us.

This is what invisible illness looks like.

The inspiration for this post came from my experience on Saturday morning. I had a hip arthroscopy two weeks ago, and on Saturday when I woke up and started to hop around on my crutches, my foot turned purple, as if all the circulation was cut off. I had a friend staying with me, and honestly, her reaction heightened my anxiety about it. I managed to keep a somewhat level head, emailed some of my practitioners and texted my brother’s partner who happens to be a doctor. Apparently this is a normal reaction after lower body surgeries. Basically I have to keep my foot elevated (at least at heart level) as much as possible. I did also go to the walk-in clinic that my family doctor works at. The doctor I saw looked at my foot and double checked that there were no blood clots, then suggested elevation and compression socks and sent me home.

Purple foot – Saturday morning surprise!

There are a couple of reactions we can have in situations like these, which, let’s be honest, happen often when you have a chronic illness. One, is fear, which, like I mentioned, is easy to be drawn to. It’s the fight-flight-freeze response, with flight or freeze usually taking over. It can be scary, overwhelming, anxiety-producing, even upsetting. It can also cause depression and sadness, because of course, something else stupid and terrible has happened to you. These are normal reactions, and short term responses like this are totally fine. The problem develops when these feelings take over, especially when you have a chronic illness because these situations, these stressors, are going to keep happening. If you are feeling like this more often than not, it’s time for some professional help. Seek out a therapist, because you don’t have to feel this way forever.

Image from: https://www.chconline.org/resourcelibrary/fight-flight-freeze-anxiety-explained-for-teens-video/

The second reaction kind of goes more with the “fight” part of the fear/anxiety response. This reaction is one I often go with which is “how am I going to solve this problem?” I do research (I will literally read scholarly journals online as well as just reddit threads – I need all points of view). I will ask the professionals I know, and the other Warriors I know. I will buy anything I need, whether I have the money or not. I will ask for help (I mean like I needed a ride to the doctor after all). This is a proactive response. The problem with this response is that it can ignore emotion. So, if you’re like me, it’s good to take some time alone to reflect, maybe use some mindfulness, get inside your body and your emotions and let them be what they are. Holding it in can make things worse in the long-term. Mindfulness will be your friend.

This is what I got with my proactive approach – a elevation pillow.

A third reaction is acceptance. It doesn’t mean you don’t experience the short-term emotions of fear and anxiety mentioned above. It doesn’t mean you don’t do some proactive things so you can take care of your body and your symptoms in the long-term. It just means that in the present moment you can understand that this is a thing that happened. It is not a reflection of you. It is (usually) not unsolvable. We all have to deal with acceptance when we have a chronic illness. I did a whole podcast episode on illness acceptance (which I will link below). This is something I strive for always. Can I be accepting when something I don’t anticipate or like happens? I would say for myself, the answer is yes. I do tend to be proactive first, then I try to use mindfulness to experience my emotions, then I try to accept reality. Is this always a perfect process? No. I do have people in my life to help me – mainly a psychotherapist and a naturopath – who are specialists in this kind of work.

Image from: https://www.smartliving365.com/the-problem-with-accepting-what-is/

I hope everyone has a great week. Reminder, I have a premium blog post coming out on Saturday, so if you’re not signed up and you want some more work on self-care strategies, it’s only $5/month and it’s well worth it. Remember everyone, keep making the most of it.

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