I developed the DOC (Direct your Own Care) program after discovering that by providing a systematic approach to dealing with all aspects of a pain problem, I could almost always help patients become more functional.
But more surprising to me was that not only would they improve, many would experience a nearly complete recovery. Patients who had been disabled for quite a while would have a remarkable resolution of their pain, come off narcotics, and resume an almost normal lifestyle. Frequently the new lifestyle was more active and satisfying than anything they had experienced before. This level of recovery went well beyond both my patients’ and my own expectations.
Changing my practice
When I moved to Sun Valley, ID in 1999, I was in the worst part of my own 15-year ordeal with chronic pain. I was experiencing many physical symptoms, including migraine headaches, thoracic back pain, tinnitus, burning in my feet, and over a dozen of the other known 33 physical symptoms of a stressed nervous system. My practice changed from being that of a complex spine surgeon at a major medical center, to becoming a primary care physician caring for all aspects of a patient’s spine problem. There weren’t many resources, so I orchestrated most of the care.
I had always been diligent in doing what I could to help patients avoid surgery, but I did not understand chronic pain. I applied a surgeon’s mindset to non-operative care. Whatever aspect of the issue arose, my goal was to solve it – and quickly. Eventually, a predictable pattern evolved as well as a structure. As I personally tried this approach, I also began to heal. When I left Sun Valley to return to Seattle in 2003, I had largely broken free from the grip of chronic pain.
The DOC project
Here is the core of the DOC project:
- Effectively processing stress
- Physical conditioning
- Medication management
- Life outlook
- Education as to the nature of chronic pain and the principles behind the solutions
- Family dynamics
- The first step that clearly made a significant difference was addressing sleep. Back then, only a small percent of physicians dealt with sleep issues. I took an aggressive approach and would begin with simple “sleep hygiene” issues. But if a patient wasn’t getting adequate sleep within a couple of weeks, I would use different combinations of sleep medications. Most people would respond within six to eight weeks. A significant percent of patients experienced a dramatic improvement in their pain. It wasn’t until years later, that I read a major paper showing that lack of sleep could induce chronic pain. (1)
- Dealing with stress was the next concept that emerged, which I discovered through expressive writing. I did not have access to a pain psychologist, so I recommended that patients read David Burn’s book, Feeling Good. Many refused to read it or they would read it but not engage in the writing exercises that he strongly recommended. The book presents a program of self-directed cognitive behavioral therapy. His research had shown that 85% of people would respond with an improvement in mood. I liked using the book because patients could immediately engage with it, whereas it would usually take weeks and months to get into a pain psychologist. Then I noticed that the only ones who responded were those who did the recommended writing.
- The physical conditioning aspect of the DOC process was not a new concept and I did have the privilege of working with superb physical therapists right next door to my office. I was introduced to a high level of evaluation and care. We were also close to an athletic club and working out with resistance training quickly became part of the program. Weight training increases strength, so there is less stress on the body. It also stimulates the release of hormones that enhance your sense of well-being. But it also seems to have a neurological component in that you are on the offensive, taking charge instead of being at the mercy of your pain.
- Medications are a significant aspect of healing, although eventually most people came off of them as their sleep and pain improved. My approach was the reverse of what is usually done. My sense was that people needed some symptomatic relief in order to engage in the other parts of the DOC process. I would keep patients on the same doses of medications they came in on, including narcotics. All medication discussions were done face-to-face. The goal was to wean down but the patient always had the last say regarding how quickly this would occur. What I did not realize at the time that anxiety is the pain and going to war over medications is counter-productive. With the patient in charge, he or she had control (an antidote to anxiety) and I rarely had a problem with patients coming off of their meds. In fact, as the pain dropped, the side effects increased and they were anxious to stop taking them. I also realized that no one really wants to be dependent on meds. The only criteria I required was that they had to be actively engaged in the other aspects of the DOC process, although I did not have a name for it back then.
- Life outlook turns out to be maybe the most important aspect of healing although it began accidentally. I had been working hard with a middle-aged woman to help her with her pain and get her back to work. It was a bit of a struggle, but she steadily pulled out of her chronic pain. When it became time to have her return to work, she told me that she never had any intention of returning to work. I became upset and realized that I had never set any goals with her. I began to ask every patient exactly why they were seeing me and what they wanted. What eventually became apparent was that goal setting is a core aspect of stimulating neuroplasticity. Your brain will develop wherever you place your attention. It is similar to learning a new language. You have to decide what you want your life to look like, what you want in it, and then pursue it. Otherwise you are still focused on the problem and not the solution. A corollary aspect of this is forgiveness. You can’t move forward until you can let go.
- Education about the nature of a problem is essential in any realm before you can solve it. This is particularly true with chronic pain because it is so complex and each individual is unique. The traditional approach to chronic pain is to manage it, not solve it. Random simplistic treatments are used to treat symptoms and not address the core problem of a fired up nervous system and sustained exposure to elevated stress chemical. My book, Back in Control: A Surgeon’s Roadmap Out of Chronic Pain evolved from my need to explain the problem to my patients. Its main role is to provide a context of care and it is helpful to be able to understand why and how different treatments work – or not.
- The final component regarding family dynamics came about over the last few years of my practice in Seattle. We had known that chronic pain takes a terrible toll on the family. It became clear that a patient could engage in many aspects of the DOC process but the family dynamics would sabotage everything. Conversely, by addressing the family interactions around pain, patients would often experience powerful healing. We began to set up rules around pain in the household. The basic one was that the patient could not discuss their pain with anyone – ever – especially with their family. The corollary was no complaining, giving unasked-for advice, or criticizing. Basically – be nice.
The DOC process provides a framework for you to organize your thinking around your pain, figure out your individual set of issues, and pursue your own journey. I have watched hundreds of patients break free from the deep Abyss of pain. There is no beginning or end point, as you will learn tools that will help you deal with day-to-day stresses. As your anxiety drops, pain decreases and creativity and joy returns. Helping people out of pain has become the most rewarding and enjoyable phase of my career.
A few years ago, I began to work with a woman in her 30’s, who had been experiencing severe anxiety when she was ten and developed widespread pain over most of her body. She continued to push forward, in spite it all. She was a talented musician but had to put a hold on it because of her pain. Her life became progressively smaller as she kept pursuing different treatments without any success.
She began to work with me on the DOC process, beginning with expressive writing and learning about pain. Sleep was a major problem and it took months to bring that under control. However, a few weeks after she began writing, she noticed an improvement in her anxiety. She also had access to a somatic therapist who was able to help her relax. Over a period of six months, her anxiety dropped dramatically, her pain resolved, she came off all medications, and she is re-engaged with her music career. She can’t express in words how happy she is to be not only free from chronic pain and anxiety, but also that she is thriving.
- Agmon, M and G Armon. “Increased insomnia symptoms predict the onset of back painamong employed adults.” PLoS ONE (2014); 9(8): e103591. doi: 10.1371/ journal.pone.0103591.