Integrated and Integrative Health for Pain Management:
An Interview with Karen Seal, MD, MPH
Karen Seal, M.D., MPH, is principal investigator of one of the Pain Management Collaboratory’s 11 pragmatic trials studying nonpharmacological strategies to manage pain and improve daily functioning and quality of life in veterans. The other PI for this study is William Becker, MD. Dr. Seal is a Professor of Medicine and Psychiatry at the University of California San Francisco and the Chief of Integrative Health at the San Francisco VA Health Care System. She also directs the Integrated Pain Team clinic and Integrated Care Clinic for Iraq and Afghanistan veterans.
Our PMC editor sat down with Dr. Seal to talk about Complementary and Integrative approaches to pain management, the PMC pragmatic trial that she is conducting with Dr. Becker., and about working with the veteran population.
While integrated care and integrative care do sound alike and relate to each other, there's a difference between the two. Integrated care is highly collaborative. It's transparent to the patient that it's not just one provider working with them, but an interdisciplinary team of providers each lending their unique perspective to the veterans’ health concerns. Integrative health, is about collaborating with the patient, finding out what matters most to them and getting them activated in doing activities that work for them, that help them self-manage their chronic pain, such as yoga, tai chi, gardening and other mind-body activities that decrease stress.
For instance, with integrated health, a patient with chronic pain comes to our Integrated Pain Team Clinic and they're able to see three providers at the same time in the same room. It’s not only efficient, but also allows patients with complex pain complaints, often involving mental health and other physical health problems, to address all of these related concerns at the same time. We've actually published multiple studies now showing the effectiveness of this integrated pain team approach in working with patients with chronic pain, especially for those veterans who depend on opioids. Generally, those patients have been prescribed opioids for a very long term, at high doses, and so they have the benefit of working with a pharmacist who can work with them on tapering their opioids gradually and a pain psychologist who works on a number of the mental health issues that often underlie chronic pain and the long-term use of opioids.
Integrative health is often practiced in integrated setting where you have several different types of providers working together with one patient, but it's integrative in the sense that it uses mind-body approaches intentionally to manage patients with chronic pain or other complaints. We're not so much in the business of saying, "Here, take this pill," or "Here, you’re going to undergo this test or procedure." Integrative health is about helping patients make fundamental lifestyle changes to nutrition, exercise, sleep and how we cope with stress. It's a much more active and less passive approach.
When a patient comes to us with chronic pain in an integrative health setting, we might not just talk about what they would be doing for their pain complaint, but we will also be asking them about how they are sleeping, what they are eating, and their daily routines for work and exercise, since feeling, eating and sleeping better improves their experience of pain. We might suggest deep breathing and meditation to improve sleep, have the patient engage with a therapist or apply cognitive behavioral approaches to help with depression or anxiety, or recommend whole fruits and vegetables in place of sugar and processed foods to decrease inflammation and improve mental health. Finally, the other area that integrative health works on is the broad area of exercise. Tai Chi, yoga, and other movement therapies are gentle movement therapies that are helpful in reducing both stress and chronic pain. In fact, almost all national guidelines from professional organizations are saying that exercise and behavioral health interventions are first line in the treatment of chronic pain.
I'm very interested in studying clinical models of care. I believe that a multimodal approach to chronic pain is really the most effective approach. There may be evidence for these individual modalities in alleviating chronic pain; however because the effects of each of these individual treatments tend to be small, it often makes sense to combine several of these mind-body modalities for a larger total effect. I would like to study this approach in a veteran population because chronic pain is so often combined with PTSD, depression or other psychosocial issues for this population. In studying the Whole Health Team approach, in which all team members—including the Whole Health coach—work closely with individual veterans, we work to relieve chronic pain by helping them make some fundamental lifestyle changes that are consistent with their overall values and goals.
Integrative health care is a different way of thinking about going to the doctor. It's not just going to the doctor and having the doctor do something to you. It asks patients to consider and be proactive about what they can do to improve their pain with the help and the support of this multi-modal, multi-disciplinary mind-body approach. So that's not for everyone. In the VA’s Whole Health approach, the Whole Health coaches can be very helpful, using techniques like motivational interviewing and working with patients over time, developing a therapeutic relationship to really help them identify and overcome the barriers to getting to that yoga class, or eating differently, so that we're actually starting to implement healthier approaches.
Several years ago, the VA rolled out Whole Health model for patient care, which is a wonderful model for veterans because it is multidimensional and patient-centered. It asks the person, "What do you value most, and what do you want your health for?" It gets at veterans’ personal goals and values so that we, as healthcare providers, are not just prescribing medications and programs for veterans based on what we think is the best thing for them, but asking them to engage with us, and co-create a personalized health plan for them.
The Whole Health Team model for this study takes a team approach to chronic pain care. The team consists of a primary care provider who is trained in a Whole Health approach; a complimentary integrative health provider (for instance, an integrative dietician, a yoga teacher, an acupuncturist, a chiropractor, or an integrative mental health provider); and a Whole Health coach, who works directly with the patient, starting with conducting what's called a Personalized Health Inventory (PHI). The PHI asks patients questions centering around the eight dimensions of Whole Health, which really get at mind, body and spirit, and tunes into the status of their emotional health, spiritual health, psychosocial functioning, where they live, personal relationships, their work, et cetera.
In our Whole Health Team model, we use the information from the Personalized Health Inventory, and we work with patients during an hour-long initial visit, focusing on their chronic pain complaints, and of course everything else that relates to chronic pain. From this, we eventually develop what we call a Personalized Health Plan or Pain Care Plan, which really represents what matters most to the veterans and what they would most like to be able to do in their lives with our support. After that, we will go on to follow patients clinically over time for up to a year. Additionally, the Whole Health coach associated with our team will provide eight additional telephone sessions—or what we call VA Video Connect sessions, which are essentially like Skype sessions—with the veteran, to help them achieve the goals that they laid out in their personalized pain care plan.
A Whole Health coach in the VA Health Care System is very broadly defined, in terms of people's expertise areas. There are a full spectrum of coaches, all of whom have training from the Office of Patient-Centered Care on Whole Health coaching, as well as supervision from a psychologist, also trained in Whole Health. For example, at the San Francisco VA Health Care System, we have a fairly robust peer specialist program, and so we have veteran peers themselves delivering Whole Health coaching to other veterans, which can be very powerful because peers have shared experience with our veteran patients. We also have social workers, nurses, and psychologists delivering Whole Health coaching as well.
Veterans are a unique population to work with because they have been through so much, not only combat-related, but also before and after combat. Those experiences really define their strengths, as well as a lot of the emotional and physical struggles they experience. I've never really found that exclusively using only my tools as an internal medicine doctor is the best way to meet the needs of veterans. I think applying a mind-body approach to most of the problems that veterans present with has always been the most useful. For instance, in working with the large population of veterans that struggle with chronic pain and Post Traumatic Stress Disorder (PTSD), it is near impossible to effectively treat the physical pain if the underlying emotional problems related to PTSD are not addressed. What's beautiful about a lot of the Whole Health and integrative health approaches is that they treat the mind, body and spirit. For example, an activity like yoga, can be a particularly powerful approach for our veterans who are struggling with both chronic pain and PTSD.
Integrative & Integrated Health Care for Managing Pain in Veterans
In the following video series, PMC Pragmatic Study PI Karen Seal, MD, MPH, explains the VA’s Whole Health model, its components, and its benefits. Dr. Seal also shares what the model does for patient care and pain management, as well as discusses using mind-body approaches to meet the unique, multi-dimensional needs of veterans with chronic pain.Watch the Video Series Featuring Karen Seal, MD, MPH