Half of the veterans participated in health psychology services beyond the initial conjoint session. Four of these veterans participated in additional conjoint sessions, and the remaining 8 engaged in health psychology services, which took the form of telephone sessions (3), in-person sessions (3), or a combination of both telephone and in-person sessions (2). Twelve veterans participated in an average of 3.4 (SD 3.7) follow-up sessions. In terms of the content of these follow-up sessions, across all formats and types, 3 included some introduction to coping skills, with no documented evidence of follow-through. For 2 of the veterans engaging in some type of follow-up, there was documented use of coping skills, and 2 used the coping skills with self-reported success and benefit. Finally, documentation revealed evidence that 3 of these veterans were not only using the coping skills with benefit, but also reported an improvement in pain management overall. One also was connected with a different service.
Regarding reasons for completion of services, 2 veterans were terminated due to completing treatment/meeting goals, 2 were terminated because they did not follow up after a session, 7 were terminated due to patient declining additional sessions, and 1 veteran was still receiving services at the time of the review. Linear regression indicated that the number of conjoint sessions was not associated with qualitative treatment outcome. Two logistic regressions indicated that number of conjoint sessions was not related to whether the veteran accepted follow-up services or whether the veteran followed through with services after accepting. Of note, logistic regression indicated that having a mental health diagnosiswas associated with a decreased likelihood of accepting health psychology services (P = .03). Regarding the independent samples t tests, veterans who did not accept follow-up services were more likely to have a mental health diagnosis (P = .03). The groups did not differ significantly with regard to substance use diagnosis or previous engagement in health psychology services.
Discussion
Results showed that all 24 veterans who were offered a conjoint session with a clinical pharmacy specialist and health psychologist engaged in at least 1 session. Half the veterans participated in further services as well. Both the initial conjoint and follow-up sessions offered a greater degree of communication related to the cognitive-behavioral and functional restoration components of behavioral pain management. Given that a majority of the sample had not participated in behavioral or mental health services previously, this may represent a greater penetration rate of exposure to mental health service for veterans than would have been available otherwise.
More specifically, qualitative results suggest that in these conjoint sessions, the veterans were exposed to behavioral psychotherapeutic approaches to chronic pain management (eg, health behavior change, motivational enhancement, health-related psychoeducation, and CBT for chronic pain) that again may not have been provided otherwise (ie, via referral and separately scheduled sessions). These findings are supported by theories consistent with the Transtheoretical Model, which indicates that individuals fall in varying degrees of readiness for behavioral change (ie, precontemplative, contemplative, planning, action, maintenance).21,22 Thus, behavioral intervention approaches must be adaptive and adjust format and communication, including the amount and type of psychoeducation offered. Moreover, the integrated theory of health behavior change in the context of chronic pain management calls for fostering awareness, knowledge, and beliefs through effective communication and education for a wide range of individuals who are at varying stages of change.23 In addition to the conjoint session and subsequent service(s) content that were reviewed and coded in this current project, future projects might draw on these theoretical models and code sessions for patients’ stages of change and assess whether a patient made progress across phases of change (eg, the patient shifted from contemplative to the planning stage of change).
Within this project’s conjoint sessions and consistent with MI principles, veterans were offered discussions related to the bidirectional and BPS aspects of their own chronic pain experience. That is, while discussing responses and adjustment to pain medication(s), veterans received reflections with MI and heard feedback related to their current coping strategies, methods to enhance coping, as well as potential psychosocial impacts of their chronic pain experience. With permission, veterans also were introduced to themes that comprised evidence-based CBT for chronic pain (CBT-CP) intervention. Understanding what change means in the context of chronic pain management is critical. That is, tipping the conversation toward consideration of alternative modalities (eg, relaxation, stress management, cognitions, and pain) in conjunction with or in place of the traditional modalities (eg, medication, pain procedures) is paramount.
Clinicians must listen for patient ambivalence related to procedures, interventions, medication changes, and/or the behavioral self-management of chronic pain. This type of active listening and exploration may be more likely when there is collaboration and effective team functioning among clinicians than when clinicians provide care independently. Future quality improvement (QI) or research projects could extend the EHR review and evaluate clinician-patient transcripts for fidelity to the CBT-CP and MI models. Such efforts could assess for associations between clinician MI consistent behaviors and change talk on the part of the patient. Furthermore, clinician communication and patient change talk from transcripts could be evaluated in relation to evidence from the EHR regarding patient use of coping skills and behavior change.
Consistent with behavioral health literature, having a mental health diagnosis was associated with declining additional behavioral health psychology services in this project. Research has shown that individuals with a mental health diagnosis tend to engage less in behavioral health self-management programs, such as chronic headache and weight management.24-26 This phenomenon lends support for the importance of health care professionals (HCPs) to increase access and exposure to mental and behavioral health services, such as the PC-MHI model.20 In fact, chronic pain management program development efforts within the VA system nationwide include collaboration with the PC-MHI services. One of the initial goals for PC-MHI services is to increase penetration rates into the general outpatient medical clinics and enhance engagement in mental health services.
Using conjoint sessions as was offered in the current project is one step in the development of more comprehensive interdisciplinary teams through interprofessional collaboration and the use of effective clinical communication. In turn, it will be important to directly explore the communication skills and attitudes of these HCPs with regard to interdisciplinary program development and collaboration as teams continue to integrate more broadly into the medical system and enhance chronic pain management services.11 Similarly, measuring the perceptions of clinical pharmacy specialists, physicians, health psychologists, or other clinical disciplines involved in chronic pain management could be another area to explore. More specific to MI, clinician confidence in the use of effective communication and MI skills represents still another area for future study.16