Michigan Behavioral Consultants is a group of eight psychologists who work primarily in pain management. Based in Grand Rapids, Michigan, with ten locations throughout Western Michigan, the psychologists work closely with Michigan Pain Consultants, a large group of anesthesiologists. A multidisciplinary team comprised of a medical doctor, a psychologist and a physical therapist, is available to each pain patient right from the start.

Eric Willmarth, PhD, President of Michigan Behavioral Consultants, has worked with pain patients for more than 12 years. During that period he has used an assortment of psychological assessments to evaluate patients and notes that most tests were not designed for pain patients. As a result, he and his colleagues conducted a search for a more appropriate assessment to meet the specific needs of pain patients.

 In 1992 Michigan Behavioral Consultants began using the P-3® (Pain Patient Profile) by C. David Tollison, PhD, and Jerry C. Langley, DC, a screening tool to help identify the psychological factors that may be delaying a patient's recovery from chronic pain, illness or disease. In 1997 they also began using the BHI™ (Battery for Health Improvement) assessment developed by Daniel Bruns, PsyD, J. Mark Disorbio, EdD and Julia Copeland Disorbio, PT, to help identify psychological and psychosocial factors that may interfere with a patient's normal course of recovery from an injury. Both instruments are normed on community samples and pain patient samples. The following account describes the BHI test and Michigan Behavioral Consultants' use of the instrument.

The BHI assessment is a comprehensive assessment tool used to: support evaluations for cases involving orthopedic, occupational and automobile injuries, workers compensation and long-term disabilities; evaluate patients' readiness for vocational training or job placement; evaluate patients' emotional readiness for surgery; evaluate treatment effectiveness and monitor clinical outcomes; and facilitate physician-psychologist communication. A wide variety of pain clinicians such as anesthesiologists, neurologists, physical therapists, surgeons, rehabilitation specialists, nurses, psychologists and psychiatrists now use the BHI test as part of their diagnosis and treatment planning.

Fourteen scales address psychological factors such as anxiety, borderline, chronic maladjustment, depression, hostility, perseverance, symptom dependency, and substance abuse; environmental factors of doctor dissatisfaction, family dysfunction, and job dissatisfaction; and physical factors of muscular bracing, pain complaints, and somatic complaints. Most patients complete the 202 multiple-choice items in 25-40 minutes. The test can be administered by paper-and-pencil, via audiocassette, or on-line. Scoring can be completed by hand, by using the Pearson Assessments mail-in scoring service, or with MICROTEST Q™ Assessment System software installed on a PC in the clinic office.

The psychologists at Michigan Behavioral Consultants receive most of their patients through referral from the patient's medical doctor. Physicians may notice the need for psychological assessment and treatment as early as the first appointment. Others may not recognize the need until the patient does not respond to medical treatment as expected.

 When psychological treatment is called for, Willmarth always uses the BHI test as the main assessment tool, along with the Beck Depression Inventory®-II and Visual Analogue Scales. He uses the MMPI-2™ assessment when more serious psychopathology may be a concern.

 The patient takes the test in an office within the clinic. Willmarth reports that patients' responses to taking a psychological assessment reflect how well the patients are prepared by the referring physician.

 "The doctors who are very comfortable with the mind-body approach make it very easy to help the patients look at psychological issues," he explained. "We believe it's part of our job to educate physicians to be comfortable with the mind-body relationship. Also, by the time patients come to a pain clinic for help, most realize that pain and mood are related, so the idea of taking a psychological assessment is not surprising."

Upon completing the test, the patient schedules an appointment to return for an interpretation a week later. Willmarth's experience has shown that both the P-3 and the BHI reports are written in a way that makes it easy for doctors to discuss results with patients.

"The first thing the patients notice when they get the interpretation is the difference between the population that has chronic pain and those that don't have chronic pain, which helps normalize issues more for the patients," Willmarth explains.

"This normalization of their issues does help make patients more receptive to coming back for therapy because it eliminates the personal issue of, 'They think I'm crazy.' The patients now understand that pain presents certain problems and behavioral counseling might help them deal with those problems more effectively."

 Until they began using the P-3 and BHI tests, Willmarth and his colleagues weren't particularly satisfied with the other tests they were using for presurgical assessments because they believed the tests were not good predictive measures. "There's not a lot of evidence out there that we can predict who will do well and who won't do well with implants. We are fooling ourselves if we think instruments can do that." Instead, he and his colleagues use the BHI test as a prescriptive measure. Prescriptive acknowledges that some patients in chronic pain will have more psychological problems than others, he states. For therapists, that means the patient may need more resources in their treatment program to help the patient be more successful.

 For example, the patient may need to be seen more frequently, or the therapist may need to make phone contact and check on the patient more often. A predictive measure rules out a whole group of people by saying they can't have certain therapies because statistically they aren't likely to succeed. While Willmarth uses the MMPI-2™ test to assess patients with more serious psychological issues, he found that those patients have the potential to be just as successful with pain management, although it may take more resources from the therapist.

Willmarth reports the results he gets from the BHI test are practical because the test addresses issues such as anger and somatization, issues that have direct impact on helping someone work through a chronic pain. He states that with the BHI test, he is "now able to get straight to the issues quicker."

Overall, he concludes, the pain experience is multi-level and has multi-level impact. "The BHI test is an effective vehicle to help us look at of the many different facets of pain management. The authors, Mark Disorbio and Dan Bruns, have done an excellent job tailoring the BHI test to meet the needs of the pain patient and to the clinician working with pain management." 

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