Countertransference with chronic pain patient

[brainmedicine]

I am a PGY-1 and I am very interested in doing therapy. One thing that is overwhelming is countertransference during my my PGY1 year. I wonder if that is normal? And what can I do to manage it?

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[Fermata]

I would prioritize patients like this during your supervised time as that is likely to be of most benefit to you. Some of those in my training program would have both a psychiatrist and psychologist as preceptors for therapy patients.

 

[splik]

patients can generate strong feelings in us. rather that something to be "managed" or brushed aside, we need to actively engage with these feelings, to understand them and use them in our therapeutic relationships with patients to help understand them and get them to better understand themselves. patients with chronic pain are a pain. They can make us feel angry, helpless, inadequate, manipulated, we may have punitive, violent, or vindictive feelings towards them. If patients are generating particular powerful feelings that you are enacting you must be 1) aware of the possibility of projective identification and 2) start to wonder why this patient is getting under your skin so much. Is it for example because the patient reminds you of a mother or aunt with chronic pain? Is it because they tap into your feelings of inadequacy being a physician or feeling like an imposter? The most effective therapists (regardless of therapeutic orientation) work in the transference and can be genuine about how they are feelings. Sometimes it can be helpful you have your own psychotherapy if you are finding yourself overwhelmed by particular responses to particular patients. I think it is completely normal for beginning residents to be blindsided by particular reactions they may have to patients or particular patient encounters, but you will learn and it is important to talk about these things in supervision. The more you don't want to talk about it with your supervisor, the more you should. I had homicidal thoughts about one of my patients when I was an intern I found him that annoying, but I realized it was an enactment of a projection, feelings he had that he disavowed on to others that led to him experiencing hostility and bullying.

Here are some examples of how one works in the transference, and uses countertransference therapeutically

Example 1:
Patient: Am I boring you? You look like you're about to fall asleep...
Therapist: To be honest, you were boring me. I noticed I was asking about you about your mom and then you went off and started talking about dresses. I'm wondering if you were deliberately boring me because it was too hard to talk about your mom.
P: I really didn't want to talk about her!
T: I'm wondering if on some level talking about uninteresting things was your way of getting back at me for trying to get you to talk about things you didn't want to...
P: I didn't realize I was doing that...it's just hard for me to talk about her and I'm not sure it's all that relevant
T: Is there anything about me that makes it hard to talk about her?

Example 2:
P: Doctors are all useless! No one has been able to help me with my pain, I don't want to live like this! I've had all sorts of procedures, I've been to chiropractors, naturopaths, I've had acupuncture, nothing really helps and no one can tell me what's wrong with me!
T: How horrible to live in such agony! You've tried so hard to find relief and are still suffering..it isn't fair
P: you have no idea how bad it is! No one is helping me!
T: You're telling me I'm useless, I'm not helping you. And I feel like I've not been helping you enough, you're still suffering like this
P: I feel so hopeless. Animals get treated better than this
T: tell me more about feeling hopeless

Example 3:
P: Am I annoying you? You must think I'm the most annoying patient ever
T: No you're not annoying me right now but sometimes I do feel annoyed with you because you're always deflecting
P: (smiling) that's what I do...why do you want me to talk about sad things? Arrrgh...I can't do it...what's the point anyway? you're just going to forget me. You're just going to leave me like everyone else.
T: P, I don't think I could ever forget you. You can be pretty annoying sometimes when you won't talk about things that matter, but now that I've gotten to know you a bit I actually really like you.
P: I like you too. I like that you keep it real.
T: I'm interested in this idea I'm going to leave you
P: well you're going to abandon me aren't you? Just like my mom did...everyone always abandons me

 

[brainmedicine]

Did you ever have countertansfernce with chronic pain patients?

 

[splik]

we have countertransference to all patients all of the time! i'm not sure if you understand quite what countertranference is. if you mean have i experienced extreme negative emotions to such patients then yes, of course i have. though narcissistic patients are the ones who really rile me up and i will not see covert narcissistic patients for psychotherapy.

 

[nitemagi]

A lot of this isn't countertransference. It's bias. Many ppl don't think about the distinction.

 

[deleted314290]

My counter transference has gotten me so far already, why would I abandon it?

 

[erg923]

"Countertransference" is really a overly loaded/complicated term. 90% of time, people seem to be simply be talking about negative reactiosn that are due to bias and preferences...not exactly some complex emotional entanglement with the patients presenting problems/issues.

 

[chicagochildpsych]

I feel it a bit, mostly it's frustration that I often have trouble getting these patients to feel better without using opiates.

 

[deleted452516]

I was on service with a very challenging chronic pain/addictions patient. The whole team was having a lot of negative emotions towards the patient and their family. Our attending brought in a print out which I found to be very helpful for my own thinking about the case and my frustration.

"The unhappy are egoistic, spiteful, unjust, cruel, and less capable of understanding each other than fools. Unhappiness does not bring people together but draws them apart."

- Anton Chekhov: Enemies.​

 

[slappy]

A lot of this isn't countertransference. It's bias. Many ppl don't think about the distinction.

This. I find it to be one of the most commonly misused terms in psychiatry. Although they left it out on this article on the 50 misused words: http://journal.frontiersin.org/article/10.3389/fpsyg.2015.01100/full

 

[Ceke2002]

Here are some examples of how one works in the transference, and uses countertransference therapeutically

Example 1:
Patient: Am I boring you? You look like you're about to fall asleep...
Therapist: To be honest, you were boring me. I noticed I was asking about you about your mom and then you went off and started talking about dresses. I'm wondering if you were deliberately boring me because it was too hard to talk about your mom.
P: I really didn't want to talk about her!
T: I'm wondering if on some level talking about uninteresting things was your way of getting back at me for trying to get you to talk about things you didn't want to...
P: I didn't realize I was doing that...it's just hard for me to talk about her and I'm not sure it's all that relevant
T: Is there anything about me that makes it hard to talk about her?

Example 2:
P: Doctors are all useless! No one has been able to help me with my pain, I don't want to live like this! I've had all sorts of procedures, I've been to chiropractors, naturopaths, I've had acupuncture, nothing really helps and no one can tell me what's wrong with me!
T: How horrible to live in such agony! You've tried so hard to find relief and are still suffering..it isn't fair
P: you have no idea how bad it is! No one is helping me!
T: You're telling me I'm useless, I'm not helping you. And I feel like I've not been helping you enough, you're still suffering like this
P: I feel so hopeless. Animals get treated better than this
T: tell me more about feeling hopeless

Example 3:
P: Am I annoying you? You must think I'm the most annoying patient ever
T: No you're not annoying me right now but sometimes I do feel annoyed with you because you're always deflecting
P: (smiling) that's what I do...why do you want me to talk about sad things? Arrrgh...I can't do it...what's the point anyway? you're just going to forget me. You're just going to leave me like everyone else.
T: P, I don't think I could ever forget you. You can be pretty annoying sometimes when you won't talk about things that matter, but now that I've gotten to know you a bit I actually really like you.
P: I like you too. I like that you keep it real.
T: I'm interested in this idea I'm going to leave you
P: well you're going to abandon me aren't you? Just like my mom did...everyone always abandons me

Putting myself in the patient's place for these examples:

Example One would have gone down like a lead balloon the moment the therapist said 'you were boring me'.
Example Two would have had me wondering exactly who was in need of therapy as soon as the words 'you're telling me I'm useless' were spoken
and as for Example Three...aww gee wasn't that such a beautiful exchange between therapist and patient, excuse me whilst I throw up.

 

[mojetter]

"Countertransference" is really a overly loaded/complicated term. 90% of time, people seem to be simply be talking about negative reactiosn that are due to bias and preferences...not exactly some complex emotional entanglement with the patients presenting problems/issues.

Agreed! ....if youre not performing psychotherapy

 

[nitemagi]

Agreed! ....if youre not performing psychotherapy

Well... you can have countertransference in any treatment relationship, not just therapy. But most of the time people are using the term to refer to any feelings they have in reaction to their patient, rather than feelings they're having where they're trying to play out a prior relationship. Such as not being able to let a patient end treatment because of a need to save them, because they're similar to a parent you couldn't save.

 

[smalltownpsych]

Counter-transference can also be positive feelings for the patient. In fact, I had difficulty early in training identifying those feelings because everyone else seemed to focus on the negative feelings and I tend to have much more of a tendency to have positive counter-transference. I usually only have one or two patients on my caseload at any particular time that evoke negative feelings. They tend to be more on the anti-social side of things and they usually don't show up much. I have never really had the strong reaction to BPD that many seem to have and think that is because I let go of my own need to control others a long time ago. Chronic pain patients can be very frustrating and case 2 that splik outlined sounds about like my exchanges with them. It is extremely important to validate their pain and their hopelessness. The rest of the world tells the patient it isn't that bad and tell them ways to make it better and the patient argues that it is that bad and nothing helps. When you find yourself being pulled into that pattern with the patient - stop it. Go back to saying, "it must be awful to be in so much pain and nobody and nothing can help."

 

[Ceke2002]

Counter-transference can also be positive feelings for the patient. In fact, I had difficulty early in training identifying those feelings because everyone else seemed to focus on the negative feelings and I tend to have much more of a tendency to have positive counter-transference. I usually only have one or two patients on my caseload at any particular time that evoke negative feelings. They tend to be more on the anti-social side of things and they usually don't show up much. I have never really had the strong reaction to BPD that many seem to have and think that is because I let go of my own need to control others a long time ago. Chronic pain patients can be very frustrating and case 2 that splik outlined sounds about like my exchanges with them. It is extremely important to validate their pain and their hopelessness. The rest of the world tells the patient it isn't that bad and tell them ways to make it better and the patient argues that it is that bad and nothing helps. When you find yourself being pulled into that pattern with the patient - stop it. Go back to saying, "it must be awful to be in so much pain and nobody and nothing can help."

Speaking as a chronic pain patient for me it depends on how the validation is given. If I feel like someone's patting me on the head and going 'there, there', it's not going to go over too well. Then again I have a feeling I might not be the sort of chronic pain patient that you and Splik are talking about.

 

[ObakeMe]

Putting myself in the patient's place for these examples:

Example One would have gone down like a lead balloon the moment the therapist said 'you were boring me'.
Example Two would have had me wondering exactly who was in need of therapy as soon as the words 'you're telling me I'm useless' were spoken
and as for Example Three...aww gee wasn't that such a beautiful exchange between therapist and patient, excuse me whilst I throw up.

As a provider and a former therapy patient, I thank you for your post here. I would want my patients to tell me if I looked bored, uninterested, preoccupied, or tired. This tells me that they trust me enough to let me know how they feel about our work together, etc. I would use this info as an opportunity to work on my skills and the therapeutic relationship. To answer with "you are boring me" is simply an unempathic and a very insensitive response. And I definitely agree that the rest of the examples in splik's post seem to be even worse. That is not working out the countertransference; it is acting out on a negative countertransference. Unorthodox and very dismissive examples.

 

[Ceke2002]

As a provider and a former therapy patient, I thank you for your post here. I would want my patients to tell me if I looked bored, uninterested, preoccupied, or tired. This tells me that they trust me enough to let me know how they feel about our work together, etc. I would use this info as an opportunity to work on my skills and the therapeutic relationship. To answer with "you are boring me" is simply an unempathic and a very insensitive response. And I definitely agree that the rest of the examples in splik's post seem to be even worse. That is not working out the countertransference; it is acting out on a negative countertransference. Unorthodox and very dismissive examples.

Thank you for the appreciation. I do think there were some good examples in with what was posted, but as a patient there just those few words and sentences I picked up that speaking personally would have gotten my hackles up immediately had it been a real life situation. I'm not in therapy for chronic pain issues, although we do occasionally deal with relaxation and exercise techniques/suggestions to help minimise my response to pain and by extension the pain itself. Anyway, I do deal with (non erotic) transferential issues in therapy, typically stemming from an abusive childhood, along with parentification and spousification, which, to give one example, has lead me to become a bit of a pathological caretaker in adulthood (childhood protective mechanism that persisted beyond the time I actually needed it).

This is an example of how my Psychiatrist formulates a response to any transference I might be unknowingly displaying in session (paraphrased, obviously):

Psychiatrist: *stifles a yawn in the middle of session*
Me: I'm sorry, I'm talking too much, I'll just shut up now.
Psychiatrist: *looks slightly taken aback* Okay, where did that come from?
Me: Well you looked like you were about to yawn, and I was worried that I was boring you, or you were sick of listening my incessant blabbing, or something.
Psychiatrist: No, not at all. You seem to have made some pretty positive insights into *insert whatever issue* since we last spoke about it. I'd really like to explore some of of that further with you. I'm sorry if it felt like I was dismissing what you had to say, it's nothing to do with you at all I promise, you haven't done anything wrong, I just had a bit of a late night last night so I'm sorry if it seemed like I checked out their for a moment. Are you okay to continue?
Me: Yeah, I'm okay. I did think you looked a bit tired when we first started the session *checks desk and surrounding cabinets for signs of coffee, notices there is none*. You don't have a cup of coffee with you? You should go grab one. I don't mind waiting.
Psychiatrist: No, that's fine, I'll grab a coffee later. Let's just get back to what you were talking about before.
Me: Are you sure, because I really don't mind waiting. You have a staff kitchen here somewhere don't you? Or there's a coffee shop just up the road, probably wouldn't take you more than 5 minutes just to quickly dash out and grab a latte or something. I can wait in the waiting room until you get back, it's no bother, really.
Psychiatrist: No, seriously I'm fine, coffee can wait.
Me: Yeah, but you're tired and caffeine might help. Are you sure you don't want me to wait while you go grab yourself a cup?
Psychiatrist: Quite sure, but thank you for your consideration. *pauses a moment and eyes me for a second, obviously formulating some sort of observation* Hmm, I'm wondering if you realise what you might be doing right now?
Me: Being considerate. *smiles happily*
Psychiatrist: Well yes, that too. But what else?
Me: Um, I'm subjugating my own needs for someone else's?
Psychiatrist: Yeah, I think you might be, just a bit.

*further discussion on transferential pathological caretaking issues then ensues*

 

[whopper]

One things I've noticed in chronic pain patients is their PCP often times do not consider certain therapeutic options that can work and aren't addictive.
Aside from the usual acetaminophen or ibuprofen or opioids theres...

SAM-E for joint related pain. SAM-E also works as an antidepressant.
Fish oil for joint related problems. Fish oil could augment an antidepressant regimen.
Gabapentin
Lyrica. Lyrica does have some potential for abuse.

 

[clausewitz2]

One things I've noticed in chronic pain patients is their PCP often times do not consider certain therapeutic options that can work and aren't addictive.
Aside from the usual acetaminophen or ibuprofen or opioids theres...

SAM-E for joint related pain. SAM-E also works as an antidepressant.
Fish oil for joint related problems. Fish oil could augment an antidepressant regimen.
Gabapentin
Lyrica. Lyrica does have some potential for abuse.

Is there any reason to believe pregabalin and gabapentin differ in their abuse potential? The residential substance abuse folks I have seen get creative with medications to get high sure seem to love them some gabapentin in my neck of the woods.

 

[Doctor Bagel]

Is there any reason to believe pregabalin and gabapentin differ in their abuse potential? The residential substance abuse folks I have seen get creative with medications to get high sure seem to love them some gabapentin in my neck of the woods.

No -- the abuse potential is present for both. It's been documented a little more for Lyrica but if anything I'd suspect gabapentin is abused more. What complicates things is that these medications may also help addicts in recovery with cravings and withdrawal symptoms.

 

[OldPsychDoc]

No -- the abuse potential is present for both. It's been documented a little more for Lyrica but if anything I'd suspect gabapentin is abused more. What complicates things is that these medications may also help addicts in recovery with cravings and withdrawal symptoms.

Cheaper and more widely available.

 

[ObakeMe]

Thank you for the appreciation. I do think there were some good examples in with what was posted, but as a patient there just those few words and sentences I picked up that speaking personally would have gotten my hackles up immediately had it been a real life situation. I'm not in therapy for chronic pain issues, although we do occasionally deal with relaxation and exercise techniques/suggestions to help minimise my response to pain and by extension the pain itself. Anyway, I do deal with (non erotic) transferential issues in therapy, typically stemming from an abusive childhood, along with parentification and spousification, which, to give one example, has lead me to become a bit of a pathological caretaker in adulthood (childhood protective mechanism that persisted beyond the time I actually needed it).

This is an example of how my Psychiatrist formulates a response to any transference I might be unknowingly displaying in session (paraphrased, obviously):

Psychiatrist: *stifles a yawn in the middle of session*
Me: I'm sorry, I'm talking too much, I'll just shut up now.
Psychiatrist: *looks slightly taken aback* Okay, where did that come from?
Me: Well you looked like you were about to yawn, and I was worried that I was boring you, or you were sick of listening my incessant blabbing, or something.
Psychiatrist: No, not at all. You seem to have made some pretty positive insights into *insert whatever issue* since we last spoke about it. I'd really like to explore some of of that further with you. I'm sorry if I felt like I was dismissing what you had to say, it's nothing to do with you at all I promise, you haven't done anything wrong, I just had a bit of a late night last night so I'm sorry if it seemed like I checked out their for a moment. Are you okay to continue?
Me: Yeah, I'm okay. I did think you looked a bit tired when we first started the session *checks desk and surrounding cabinets for signs of coffee, notices there is none*. You don't have a cup of coffee with you? You should go grab one. I don't mind waiting.
Psychiatrist: No, that's fine, I'll grab a coffee later. Let's just get back to what you were talking about before.
Me: Are you sure, because I really don't mind waiting. You have a staff kitchen here somewhere don't you? Or there's a coffee shop just up the road, probably wouldn't take you more than 5 minutes just to quickly dash out and grab a latte or something. I can wait in the waiting room until you get back, it's no bother, really.
Psychiatrist: No, seriously I'm fine, coffee can wait.
Me: Yeah, but you're tired and caffeine might help. Are you sure you don't want me to wait while you go grab yourself a cup?
Psychiatrist: Quite sure, but thank you for your consideration. *pauses a moment and eyes me for a second, obviously formulating some sort of observation* Hmm, I'm wondering if you realise what you might be doing right now?
Me: Being considerate. *smiles happily*
Psychiatrist: Well yes, that too. But what else?
Me: Um, I'm subjugating my own needs for someone else's?
Psychiatrist: Yeah, I think you might be, just a bit.

*further discussion on transferential pathological caretaking issues then ensues*

It sounds like you have a great repoire with your psychiatrist. I have read some of your other posts before. That is awesome! You seem to be a very considerate and caring individual. I think in this sense it was normal to offer him suggestions especially if you weren't (i am assuming) his last patient of the day, and he would have had to struggle throughout the day. It was a very caring thing to do on your part. I am in no way going against your doctor or your therapy. I just feel this way about what you wrote here. Again, AWESOME repoire. He sounds like a keeper.

 

[Ceke2002]

It sounds like you have a great repoire with your psychiatrist. I have read some of your other posts before. That is awesome! You seem to be a very considerate and caring individual. I think in this sense it was normal to offer him suggestions especially if you weren't (i am assuming) his last patient of the day, and he would have had to struggle throughout the day. It was a very caring thing to do on your part. I am in no way going against your doctor or your therapy. I just feel this way about what you wrote here. Again, AWESOME repoire. He sounds like a keeper.

Thank you for your kind praise. It was about the middle of the day, and he was absolutely right to pull me up on what I was doing. I'm the patient, it's not my job to take care of my Doctor - especially considering he has already detailed the myriad of things he has in place to take care of himself in regards to the type of work he does (and besides that it would constitute a role reversal and I don't consider that a good thing in a therapeutic relationship). Now maybe if I'd made the offer of my Psychiatrist taking 5 to grab a coffee for himself just the once, that could be considered me just being considerate. But I didn't stop there, I kept going on about it, and becoming more and more insistent. That's not me just being considerate, that's me slipping into a transferential pattern that was formed in childhood that I'm not always aware of doing - and I need to form awareness of things like this, hence they need to be pointed out to me and discussed in session if and when they arise.

And yeah I do have a good rapport with my Psychiatrist , and considering I've been working with him for a little over 5 years now (and will probably be working with him for another 5 years after that) I'd also say he's already a 'keeper'. 🙂

 

[nicnic]

As a PGY-1 did you guys have supervision where you could discuss countertransference? I guess I have tons of supervision during rounds and through the day but not really private dedicated time to talk about how I'm feeling.

 

[masterofmonkeys]

I'm like a walking case study on countertransference to chronic pain. Mostly ridiculously negative, on occasion positive. Which is even more hilarious given that pain and chronic illness are a group that I want to focus on clinically. Or not hilarious at all if you understand it lol.

Without going into too much self-disclosure, I've literally forgotten what it's like not to be in constant pain, but I've also never used an opioid outside of Tussin DM for cough suppression. I also have lived a pretty 'normal' life by dint of entirely too much time in the gym, and to quote Pratchettt 'sheer bloody-mindedness'. Which puts me in the odd position of understanding what it's like to live in chronic unrelenting pain while at the same time not really resembling 'chronic pain patients' at all.

What helped me the most was comparing and contrasting my attitudes to BPD vs. Chronic Pain. Like smalltownpsych, I've never had any issues with negative countertransference with patients with BPD--if anything I have a slight positive one to them. Chronic Invalidation +/- Severe Trauma = BPD. Nowhere in that equation lies any space for me to dislike my patient lol. On the other hand, every time I have a chronic pain patient I get pissed off and judgmental. Because I'm probably going to have to listen to someone with 'low back pain' whine about how tough it is when I'd trade their spine for mine in a heart beat.

What helped is stepping back and recognizing that yes, while there is far more an element of personal choice in a chronic pain patient's behaviors than in someone with borderline personality, there are a LOT of external factors that go into this veritable crisis of the Western world. There's the societal attitude that all pain must be salved. There's the fact that a lack of distress tolerance is rewarded in many areas of life, from attention, to getting out of responsibility, to getting paid to be sick. Then there's the medical attitude. Pain is a vital sign!?!?!?! SERIOUSLY!??? We judge 'quality of care' based on a patient's pain self report in the hospital. Nurses and docs get in trouble if the self report is too high. So we load them up to shut em up. And well-meaning PCPs start patient's on low dose opioids for chronic pain (almost NEVER indicated btw), because 1) they want them to feel better and 2) thy don't know what else to do and 3) Shut up and get out of my office. Heck, it's even in our language. We claim to 'treat' pain (NOpe, can't be treated only managed).

And no one ever has a conversation with the chronically ill/chronic pain patient about attitude, schedule management, adjunctive methods, exercise, behavioral activation, distress tolerance, catastrophization, pain vs. dysfunction, adjustment issues, and quality of life until they've already either 1) become addicted to opioids 2) become an annoying 'problem patient' 3) become oversurgerized or 4) lost everything.

I was lucky, I was a former high level athlete, didn't even understand how badly I was messed up until years later, had a supportive family, and was raised in the concepts that are core to mindfulness-based practice and acceptance and commitment therapy (Buddhist). Don't get me wrong, there was and is still a lot of hard work I had to choose to do, but I was equipped with the tools to undertake that work. Recognizing that was incredibly important for me. Also helped give me some perspective on the dueling motivations for why I felt driven to work with people with chronic illness. The narcissistic show-off, the savior complex, etc, from the desire to help people realize there's a better option out there. Learning about the philosophy behind MOtivational Interviewing helped me quite a bit too.

So, these days, I enter into the relationship with the understanding that a lot of people--including many in a position of authority of the patient--have helped teach them to have the responses and behaviors they have. It helps quite a bit. And then I realize what my role really is, to offer them a different view, a different way of thinking about and living with pain. And if they're willing to, join me while we come up with an action plan.

 

[ObakeMe]

As a PGY-1 did you guys have supervision where you could discuss countertransference? I guess I have tons of supervision during rounds and through the day but not really private dedicated time to talk about how I'm feeling.

I am not a physician. But during PA training and fellowship training, we were able to discuss countertransference issues that came up either privately or non-privately. I never felt the need to bring it up, although I did experience some countertransference issues with patients as I was dealing with pain myself. I regret not doing so; it would have been a good opportunity to have explored some of these issues as a clinician.

 

[Shikima]

One of the big things with chronic pain is that they'll come into the office bemoaning how terrible it is. They're looking for a magic cure. Helping them realize that you cannot take it away and develop a plan that they want to invoke will spare you a lot of headaches. Don't take it on as yours to own because that's their goal.

 

[Ceke2002]

I'm like a walking case study on countertransference to chronic pain. Mostly ridiculously negative, on occasion positive. Which is even more hilarious given that pain and chronic illness are a group that I want to focus on clinically. Or not hilarious at all if you understand it lol.

Without going into too much self-disclosure, I've literally forgotten what it's like not to be in constant pain, but I've also never used an opioid outside of Tussin DM for cough suppression. I also have lived a pretty 'normal' life by dint of entirely too much time in the gym, and to quote Pratchettt 'sheer bloody-mindedness'. Which puts me in the odd position of understanding what it's like to live in chronic unrelenting pain while at the same time not really resembling 'chronic pain patients' at all.

What helped me the most was comparing and contrasting my attitudes to BPD vs. Chronic Pain. Like smalltownpsych, I've never had any issues with negative countertransference with patients with BPD--if anything I have a slight positive one to them. Chronic Invalidation +/- Severe Trauma = BPD. Nowhere in that equation lies any space for me to dislike my patient lol. On the other hand, every time I have a chronic pain patient I get pissed off and judgmental. Because I'm probably going to have to listen to someone with 'low back pain' whine about how tough it is when I'd trade their spine for mine in a heart beat.

What helped is stepping back and recognizing that yes, while there is far more an element of personal choice in a chronic pain patient's behaviors than in someone with borderline personality, there are a LOT of external factors that go into this veritable crisis of the Western world. There's the societal attitude that all pain must be salved. There's the fact that a lack of distress tolerance is rewarded in many areas of life, from attention, to getting out of responsibility, to getting paid to be sick. Then there's the medical attitude. Pain is a vital sign!?!?!?! SERIOUSLY!??? We judge 'quality of care' based on a patient's pain self report in the hospital. Nurses and docs get in trouble if the self report is too high. So we load them up to shut em up. And well-meaning PCPs start patient's on low dose opioids for chronic pain (almost NEVER indicated btw), because 1) they want them to feel better and 2) thy don't know what else to do and 3) Shut up and get out of my office. Heck, it's even in our language. We claim to 'treat' pain (NOpe, can't be treated only managed).

And no one ever has a conversation with the chronically ill/chronic pain patient about attitude, schedule management, adjunctive methods, exercise, behavioral activation, distress tolerance, catastrophization, pain vs. dysfunction, adjustment issues, and quality of life until they've already either 1) become addicted to opioids 2) become an annoying 'problem patient' 3) become oversurgerized or 4) lost everything.

I was lucky, I was a former high level athlete, didn't even understand how badly I was messed up until years later, had a supportive family, and was raised in the concepts that are core to mindfulness-based practice and acceptance and commitment therapy (Buddhist). Don't get me wrong, there was and is still a lot of hard work I had to choose to do, but I was equipped with the tools to undertake that work. Recognizing that was incredibly important for me. Also helped give me some perspective on the dueling motivations for why I felt driven to work with people with chronic illness. The narcissistic show-off, the savior complex, etc, from the desire to help people realize there's a better option out there. Learning about the philosophy behind MOtivational Interviewing helped me quite a bit too.

So, these days, I enter into the relationship with the understanding that a lot of people--including many in a position of authority of the patient--have helped teach them to have the responses and behaviors they have. It helps quite a bit. And then I realize what my role really is, to offer them a different view, a different way of thinking about and living with pain. And if they're willing to, join me while we come up with an action plan.

I can relate to a lot of this. I've had chronic pain issues since my late teens, and I'm 43 now so however long that is. I became one of those 'annoying problem patients' or rather I was assigned that role because of a lot of Doctors preconceived notions regarding young people and chronic pain. Yes I was taking a lot of drugs in my 20s, but when I was looking for a) a diagnosis, and b) treatment for my pain issues I wasn't actually looking to just score some good drugs. I genuinely wanted proper treatment, not to wipe the pain out completely, but to manage it better and to also get some assistance/ideas to help with the movement and fine motor control difficulties I was having. And almost every time I'd front up to yet another Doctor and start going through my history, symptoms, etc invariably they'd take one look at me, make an on the spot judgement, throw some pills at me (not necessarily narcotics) or just refer me onto someone else to deal with (and then I'd have to go through the whole shoot and shebang all over again - 'Oh you're a 20 something female, who dresses in alternative manner, and you say have chronic pain issues? Yeah, okay, whatever, let me just go through the motions here'). I did end up visiting some of the not so legit Doctors I knew at the time, not because I was seeking high level narcotics (although that's pretty much all they prescribed) but because they were some of the only Doctors I could see who I knew weren't going to make a snap judgement. I had a couple of Doctors along the way who did try and help, but mostly they were rescuer types who bailed when they didn't get a diagnosis and miracle cure in a set amount of time (had the same thing happen in regards to mental health issues as well). So by the time I started seeing the GP I had before I transferred to my most recent one, I was disgruntled, disenchanted, and pretty much had adopted the attitude of 'No one else has bothered to help me, what makes you so different'. But to her credit she spent time building a relationship with me, and listening, and actually taking me seriously, and advocating with other Doctors, and after more than a decade of having numerous Doctors just roll their eyes at me, I finally had a proper diagnosis and treatment plan (Tramadol for Peripheral Neuropathy, augmented with exercise, meditation and stress control to reduce perception of pain). These days I've kind of just learnt to modify my life around my condition in a way that allows me to do the maximum I can do, my new GP takes care of my medication and monitors both my pain control and any other neuropathic related issues, and I occasionally gripe to my Psychiatrist for a few minutes here and there if I've had a particular bad run, but apart from that I pretty much just get on with it.

My husband went through a similar experience - severe migraines, chronic spinal pain, sudden leg weakness leading to drop attacks. In high school he was part of the State Junior Cricket team and slated to potentially move up to a National level, and he had to give all of that up when his symptoms became unmanageable. So cue a parade of Doctors who couldn't find anything wrong, after performing a few cursory tests, and then it became a case of 'You're making this up, you're being an attention seeker, it's all in your head, you need to see a Psychiatrist, and so on'. He did eventually manage to get back into an exercise regime when he started learning and practicing martial arts and combat sports on and off, but he was still held back by his (as then still undiagnosed) condition and found he could only push himself so far before his body turned around and said 'Eff you'. Last year, after he'd been forced to take an extended break from yet another martial arts/combat defence practice he was keen to train in (and with some not so subtle prodding from me), he finally agreed to speak to our GP regarding what was going on and his history of chronic pain issues in general. One referral for a bone scan later, something no one had thought to do prior, he now has a diagnosis of Fibrous Dysplasia of the lumbar region, with an L5 pars defect and osteoarthritis of the joints. Hey presto he's now on medication that is managing his symptoms, he's easing back into training, and his confidence level is on the rise. But the entire experience has left him with a distrust of a lot of Doctors and a tendency to jump to the defensive if someone asks the wrong questions or says the wrong thing (even if they didn't necessarily mean to).

 

[ObakeMe]

One of the big things with chronic pain is that they'll come into the office bemoaning how terrible it is. They're looking for a magic cure. Helping them realize that you cannot take it away and develop a plan that they want to invoke will spare you a lot of headaches. Don't take it on as yours to own because that's their goal.

I didn't own it. I just knew what they were going through. I had a herniated disc and none of the treatments alleviated my pain: I went to physical therapy and did everything they told me to do; I did common sense things on my own such as watching my posture and losing weight; I had injections and used a traction device. NOTHING ALLEVIATED my pain. Medication just made me sick. The doctor was not willing to do surgery even after every treatment was explored. But, thank God I found another doctor that was able to help me.

The point is I felt for the patients because I KNEW what it was like to be in EXCRUCIATING pain when none of the treatments worked. I never thought that they were a pain in the a^&. I remained empathic to their situation.