Practical Pain Management Articles by Terri A. Lechnyr, PhD, LCSW

• “Taxonomy of Pain Patient Behavior” Download
  By Ron Lechnyr, PhD, DSW, Henry H. Holmes, MD

Autonomic Nervous System

HRV biofeedback allows clients and practitioners to get an intimate look at the variableness of the heart, the heart’s health, and the coherence between the sympathetic and parasympathetic neural systems.  The sympathetic nervous system is also known as the fight or flight system, where the body prepares to react to a dangerous situation with resulting increases in fear, anxiety, anger, irritability, and aggression.  When someone is suffering from chronic pain, the the fight or flight system is over-active, thus not allowing the body time to heal.  Being in long-term pain can be very traumatic to the body, thus decreasing healing, lowering immunity levels, and decreasing optimal sleep quality.  With the external feedback loop in real-life time, we get evidence-based treatment to help promote healing, modulate moods, increase concentration, focus, increase sleep quality, reduce pain flare-ups, and improve emotional well-being.

Additional information/references:

Barrios-Choplin, B., McCraty, R. and Cryer, B. An inner quality approach to reducing stress and improving physical and emotional wellbeing at work. Stress Medicine. 1997; 13:193-201.

H.Cohen, L.Neumann, M.Shore, M.Amir, Y.Cassuto, D.Buskil. Autonomic dysfunction in patients with fibromyalgia: Application of power spectral analysis of heart rate variability. Seminars in Arthritis and Rheumatism, Volume 29, Issue 4, Pages 217-227

Lehrer, P., Smetankin, A. and Potapova, T. Respiratory sinus arrhythmia biofeedback therapy for asthma: A report of 20 unmedicated pediatric cases. Applied Psychophysiology and Biofeedback. 2000; 25(3):193-200.

Luskin, F., Reitz, M. and Newell, K. Pilot study of a group stress management training on elderly patients with congestive heart failure. Journal of Cardiopulmonary Rehabilitation. 2000; 20(5):303.

McCraty, R., Barrios-Choplin, B., Rozman, D., Atkinson, M. and Watkins, A. The impact of a new emotional self-management program on stress, emotions, heart rate variability, DHEA and cortisol. Integrative Physiological and Behavioral Science. 1998; 33(2):151-170.

McCraty, R. HeartMath learning enhancement programs improve academic performance and behavior in school children. In: Proceedings of the Futurehealth Winter Brain Meeting. Miami, FL, 2001.

McCraty, R., Tomasino, D., Atkinson, M. and Sundram, J. Impact of the HeartMath self-management skills program on physiological and psychological stress in police officers. Boulder Creek, CA: HeartMath Research Center, Institute of HeartMath, Publication No. 99-075.

McCraty, R., Atkinson, M. and Tomasino, D. HeartMath risk reduction program reduces blood pressure and improves psychological well-being in individuals with hypertension. Manuscript in preparation.

McCraty, R., Atkinson, M. and Lipsenthal, L. Emotional self-regulation program enhances psychological health and quality of life in patients with diabetes. Manuscript in preparation.

Rein, G., Atkinson, M. and McCraty, R. The physiological and psychological effects of compassion and anger. Journal of Advancement in Medicine. 1995; 8(2):87-105.

Rozman, D., Whitaker, R., Beckman, T. and Jones, D. A pilot intervention program which reduces psychological symptomatology in individuals with human immunodeficiency virus. Complementary Therapies in Medicine. 1996; 4:226-232.

Provider Issues

Providers, from all professions, have a basic desire to be helpful and provide assistance to others. There is a desire to provide patients with high quality care that is based on years of study in their field. There is a desire to integrate into patient care the most recent advances and new techniques. After years of study, and provider-delayed gratification required to complete professional education, there is a hope that patients will be grateful, open, accepting and unquestioning about services offered.

If the provider has specialized in a specific area of chronic pain treatment, there is a belief that their training should be one of the major factors that will be of help to suffering patients. Reality, however, is complicated by the demand of daily practice to see more and more patients; the expectations of insurers for a quick and complete cure; the concerns of employers who are focused on the bottom line; the demands for documentation, paperwork, forms, etc.; the impact of legal, along with attorney involvement in a case; and issues of financial constraints and reimbursement issues — all of which limit what can be done for patients. Time pressure leaves the provider feeling constantly under the gun to accomplish more, see more patients, and do the required paperwork within a limited period of each day’s time.

Patient Issues

Most people hope that they will remain healthy most of their lives. They expect that they will be exempt from physical problems and difficulties. Most hope that they will not have to be involved with the health care field. They have little desire to have their days revolve around doctor appointments. Instead they hope to focus on their daily lives, jobs, family, and other private things of life that are governed by their own private logic. When patients are faced with complex health care issues, such as chronic pain, they find themselves confronting their own mortality and limitations. However, there is a belief that contacting the right provider will solve all their problems and they can then return to their usual lives without any hardship.

They also expect that the practitioner they consult will know what to do or will refer them to the appropriate specialist to fix their problem. As as result, they turn to providers as one would turn to an omniscient being. They expect that the provider will take the time to exclusively focus on them and their problem. They also expect the provider to allow them to talk at length about all the issues involved in their problem expect that the provider is interested in everything that the patient has to say. According to business marketing, as well as psychological advisors, clients only want to feel that they matter and that the interlocutor personally cares about them. There is a fear that with their disability and limitations that they will become invisible and no one will notice them again. They feel they are melting away from interactions in society where they previously had a role but now feel that “nobody knows their name.” All of this is complicated by the constant broadcasting of health information on TV and radio discussing the lastest medical advancement which will solve the most difficult of medical problems.

Added to this mix are independent medical examinations where the patient feels that the examiner is more of an agent of the insurer, and from which they receive little information about their condition or what they can do to obtain help. When quick solutions are not found, patients are frequently upset, confused, depressed, angry — all of which result in a sense of exhaustion and hopelessness. Some patients feel that providers have been authorative, directive, unsympathic, and have not answered their questions. They feel their fears and feelings are not valued or understood. When seeing a new provider, they frequently expect the same rejection they perceived in previous providers resulting in an initial tension filled interaction. Patients may present as scattered, reactive, panic-stricken, voluble, dramatic, vulnerable, and overwhelmed. They may have had “a bad day” and feel the need to take it out on the world. When one feels vulnerable, it is typical to strike out at others. At the same time, they also want to feel nurtured and valued as special human beings.

Chronic Pain Mythology

All of these interactions, and expectations, are further complicated by the unstated myths that surround issues of chronic pain. These include perceptions that chronic pain only happens to those who have psychological problems, early childhood abuse, chemical abuse, or those who are psychologically weak and vulnerable. There is also a belief that the majority of chronic pain patients are wanting to get out of work and live off disability benefits benefits. Conversely, when patients balk at what a practitioner says or offers, this only confirms more of what some practitioners have come to believe about the resisting pain patient.

This is further reinforced by the fact that a few patients do tend to appear to complicate the lives of providers by their perceived lack of motivation to improve or expend effort to help themselves. Though this does not happen with the majority of chronic pain patients, the complexity of the syndrome — along with the fact that one’s views are always based on the few negative experiences encountered — there is a tendency to generalize this view to all patients.

Unconscious Interactions

The author remembers once reading a book on marital counseling with a chapter on mate selection which was titled “One’s Unconscious Speaking to the Unconscious of the Other.” It went on to describe how one picks others to interact with that meet some type of unconscious need or pattern to which one reacts instinctively without thinking. This is one reason why most tend to gravitate toward the same types of relationships regardless of the logic involved in the situation. In fact, most interactions and choices in life are based on one’s own private logic, i.e., something that makes sense to our inner needs and perceptions about the world and others. This typically happens also in regard to professional relationships.

Each person brings to bear on an interaction issues, needs, fears, frustrations, based on past interactions in the present, and more importantly, from the past. The situation is further complicated because one is not aware of this happening consciously. So the very act of two people interacting results in a dual-dynamic which is acted out unconsciously by both individuals. The negative reactions may be sparked by a number of factors including issues of the gender of the patient and provider, the voice tone of each, the posture, who the other person reminds us of from our past, along with our needs, wants and desires, fears, suspicions, and disappointments. Even though practitioners are frequently aware of issues that the patient brings to bear in the professional interaction, they themselves seldom stop to think of how their own similar unconscious issues may be changing the quality of the interaction. As much as practitioners may want to deny it, they are constantly impacted by interactions throughout the day and certain stimuli may cause their unconscious to react in unexpected and unknown ways.

Transference

Since Sigmund Freud first conceptualized approaches to therapy, psychologists have known that all professional, as well as interpersonal, relationships involve the
concept of transference. This is seen as the patient transferring patterns of interactions and expectations — in an unconscious manner — into the present real relationship.
Frequently this is conceptualized as the patient reacting to the professional as though he/she is a parental figure. Depending on the quality of that relationship, the patient can react to the present interaction in a positive or negative manner. There should be, on the part of the professional, an awareness that transference is a normal part of the therapy process which needs to be understood and dealt with if the patient is to make a therapeutic improvement. While it does not always have to be acknowledged and analyzed as part of the treatment process, it does need to be understood along with knowing how to manage the transference so that neither party gets caught up in past issues and interactions. It is the curative effects of a corrective emotional relationship experience — in the present situation — which is therapeutic and essential to a positive outcome. When people are transformed into patients, they find themselves feeling increasingly dependent on parental figures for support and help. At these times, patients do tend to regress in functioning and often to previous levels of dysfunction. This may increase a sense of panic and dependency strivings that can be overwhelming to the patient and anyone with whom they come in contact — especially health care authority/parental figures. In fact, crisis theory suggests that in the midst of a crisis people tend to look sicker than they actually are. This enhances the transference relationship in both positive and negative ways requiring an increased professional awareness of the interaction.

Counter-Transference

Professionals, themselves, also have subconscious reactions based on their own issues — both resolved or unresolved —from the past. Practitioners therefor react to patients based on their own experiences, desires, beliefs, fears, dependency needs, vulnerabilities, etc. In so doing, they transfer emotions onto the patient that are unconscious and based on their own private logic system. However, in professional interactions, it is critical for professionals to become aware of their own counter-transference tendencies which are, in turn, are unconscious reactions to the patient’s own unconscious transference. Theodore Reik, Ph.D., a noted psychoanalyst who trained with Freud, talked of the importance of the provider having a “third ear” which is constantly scanning for messages and meanings in the patient’s communications, behaviors, withholding of information, and frustrations. He also talked of how one’s counter-transference could be useful for therapeutic diagnostic assistance and to help to guide proper responses. Understanding counter-transference requires a degree of personal awareness that develops over time. It involves observation and introspection to understand one’s own responses to patients. For example, counter-transference may include a tendency to be parental toward patients, authoritarian, dogmatic, impatient, critical, resentful of questions, enabling, too helpful, aroused, desirous, angry, resentful, or too rigid, to name a few. Instead of using any insight, or therapeutically helpful reaction, one may be tempted to misuse the information to instead label or find fault with the patient. Though there may be some truth in one’s impressions of — and reactions to — certain patients, unconscious counter-transference reactions may control the interaction.

Projective Identification Defenses

There is little discussion in the literature about how the other person’s psychological defense mechanisms can influence how we interact with them. Defense mechanisms
are ways for the person to deal with the world in order to protect themselves psychologically, e.g., denial, rationalization, identification with others, etc. One particular defense mechanism that one rarely hears about is what is known as “Projective Identification.” This technique is used to blame others for what one is feeling or experiencing. In essence, the individual is saying that “I don’t have the problem — you do!” It is a way of justifying one’s particular view of the world using one’s own private logic. Projective identification defense complicates an interaction causing the other person to react with the felt emotion that the individual is trying to evoke, or project, in some semi-conscious manner. For example, one person may feel angry and frustrated themselves, but through projective identification they can get the other person to react with those same feelings. Children are masters of this when they passively-resist attempts to involve them in meaningful interactions.

Parents become upset and angry, frustrated and confused, while the child is feels “powerful” and relishes the whole experience. When one experiences emotions of the other person, one may act out those emotions in inappropriate ways. When this happens, one may get blamed by others — and oneself — for over-reacting. In reality, it is the behaviors and emotions of the other person that were projected onto oneself. As a result, one subconsciously identifies with the projected emotions in ways that are hard to explain. Many times, these reactions are tied to one’s own past fears and needs — making one feel even more intensely about the situation. These precipitated emotions can include, anger, explosiveness, resentment, confusion, dependency, the desire to take care of others, and so on.

Solutions

What is important is that providers have to first admit that dealing with patients in chronic pain is a difficult and, at times, exhausting process. In some ways, the profession is akin to what police officers have to deal with when they only see a certain side of the population. When faced with angry, defensive, resisting people on a daily basis, it is easy to come to believe that all of humanity is negative. In turn, like the police officer, it is easy to become bitter and resentful at the demands made upon providers.

Even though a provider may know better and see many “good patients,” becoming burned-out on a few difficult patients may color expectations of pain patient interactions. One then stops adapting, adjusting, or even trying new approaches, in favor of just reacting in order to “keep them at bay” with all of their demands and problems. It is tempting to label patients as ungrateful, demanding, manipulating, controlling, or malingering. Though there may be some truth in such descriptions, each of these labels could have both positive and negative ways of viewing behaviors. Much depends on whether or not the provider is open to examining his/her own reactions to patients. For example, talking down to patients only reinforces the patients’ sense of feeling like children or victims. This may only increase the use of the aforementioned patient behaviors in an effort to force the situation and precludes the patients receiving help to understand the impact of their behaviors on the therapeutic interactions.  It is useful to remember what marketing consultants often stress to their clients: practitioners may believe they offer excellent client services, but instead their services are more focused on their own practice needs than on making the client feel valued, nurtured, listened to, and understood.

Finally, some providers just have a poor bedside manner and don’t care about it. This may have been shaped by a number of factors ranging from the providers personal style to the pressures of an every day practice. More recently, it may have been shaped by the pressures of managed care with a business orientation to the bottom line while sacrificing a positive provider-patient relationship. The bottom line orientation has forced many providers into a natural defensive posture where they are required to manage costs and to block specialty care in order to improve the profit margin of the insurer. There is an emphasis on patients who misuse, or over-utilize, the system forcing a systemic tendency to find fault and label the patient as the cause of cost-over-runs. Lower reimbursements has forced providers to see more patients in less time in order to pay the overhead. At the same time, some providers believe that they know best and the patient needs to conform to their views if they want to get better. Others believe that any problems in patient interactions does not apply to them. They think that such discussions are directed at “those other providers” resulting in a lack of personal awareness or concern for what is happening in their own interactions. All of this blocks the development of realistic and long-term cost-effective services.

Some common sense steps to improving provider-patient interactions.

1. Stop and ask “what is happening in the interaction?” Situations can be so filled with emotions (eg. resentment, irritability or anger) that one cannot be sure of “what just happened.” When the practitioner senses that he/she is reacting very strongly in an unexplained manner, it is time to stop and evaluate. By taking time to step back and consider the situation, one can start a process of more objectively observing interactions. One has to remember that feelings should not be the basis for action or reaction in a clinical setting.

Nevertheless, the patient may re-double efforts to “project emotions” for an extended period of time when not getting the anticipated reaction from a practitioner. These emotions tell us something about what is happening in the interaction and what the patient is struggling with. Working to keep an emotional distance allows the practitioner to observe his/her own reactions and emotions not as action-oriented but as diagnostic, instead.

2. Objectively decide what to communicate to the patient. Work at communicating only clinically-useful dialogue rather than what an emotional patient may want the practitoner to feel and react to. The nature of the interaction can be changed from reacting to knowing how to act in a realistic and helpful manner. Responding differently is what becomes the therapeutic model that allows for healthy growth and change over time.The clinical communication should be done in a clear and succinct fashion followed by an immediate disengagement from the interaction before getting caught in extraneous emotions. There is nothing wrong with saying “no” as long as it can be done calmly and professionaly — without resentment, irritability or anger.

3. Understand a patient’s defensive ‘Projective Identification’ and how to avoid it’s pitfalls. Understanding a patient’s psychological defense mechanism of ‘Projective Identification,’ the practitioner can start to make changes in how to personally respond. In recognizing this behavior, the practitioner can become empowered in new ways — thinking differently and reacting more realistically — so that provider-patient relationships will change over time.

It takes away the blaming and focuses on what is happening in the interactions. It also imparts new powers to handle interactions better as long as one doesn’t let one’s own needs and psychologically-unresolved issues cloud perceptions and get in the way. However, it important to note that identification of this behavior cannot always be successfully “interpreted” to the patient. Often the patient will strongly deny it and turn all the blame back on the practitioner.

4. Review one’s own myths and beliefs about chronic pain patients. Practitioners must look at their own myths and beliefs about chronic pain patients and examine how easy it is for human beings to blame others for situations. One has to look at how these views and beliefs are self-limiting and may cause the practitioner to react in a negative manner to patients. The practitioner must to look at his/her own behaviors, including potential issues in communicating easily and making the patient comfortable in the interaction.

5. Understand one’s own fears of vulnerability and disability in life’s struggles. Practitioners must come to terms on how their own fears of vulnerability and disability get in the way. Professionals have spend years educating themselves, delaying gratification, putting off family, finances, and pushing themselves, working with little sleep, all at great odds, to overcome and keep moving forward. Having worked hard to overcome difficulties, it is easy to resent or be angry at those who do not possess the same drive and seem to have given up trying to overcome their disability.

6. Examine personal/professional insecurities and acknowledge that one won’t always have an answer. Practitioners must realize that situations often present themselves for which an answer is not readily discernable and these should not be a cause of personal or professional insecurity. Without this recognition, one may become embarrassed for not knowing, not having the answer, not having words to put thoughts into action, and find themselves becoming even more controlling, authoritarian, directive, and angry with patients who question or do not follow directions without comment.

7. Understand and avoid Counter-Transference Rage. Counter-transference rage describes a situation where the practitioner becomes angry and upset with patients, defensive, reactive, or demanding in response to a patient’s question or request. It is often better to answer the question or request even if inconvenient at the moment so that later, after thinking about it and how to phrase it, one can discuss it therapeutically separate from the needs and emotions of the present situation. It is often the case that when one reacts quickly — to what may turn out to be an unconscious interaction — one frequently “puts one’s foot in their mouth” and unnecessarily poisons a relationship.

8. Put oneself into the shoes of the patient. Practitioners will find it useful to recall instances where they themselves where in a dependent position having to deal with an authority figure having more control over their life than they did. Analyzing what they would have wanted the authority figure to do in such situations when they themselves were feeling out of control may help to find ways to move it out of a regressive parental-child type of interaction into one of an interaction among equals in some manner. It is important to find ways of insuring the competency of the patient so that in the future they will have had a positive corrective emotional experience which will allow them to ask and interact in more appropriate ways.

9. Listen to what the patient has to say. Often, patients are fearful that no one is listening to them. They have pent-up frustration over what has happened to them, how they perceive that they have been treated in the past, and the general lack of information they have received about their condition and what needs to be done. It is hard for many of them to accept that their lives have changed and they will to need to make adjustments. Many times it is important to have a session where the patient is just able to vent and talk out their concerns so that they feel less misunderstood and less alone with their condition. During the patient’s monologue the practitioner does not have to say anything except to actively listen and be actively supportive. Once the patient has vented frustration, it is useful to say something like: “I know that things are difficult and the entire situation is frustrating. You need to be able to talk all this out if you are going to figure out what to do next. I cannot help you with this but it might be helpful if you could talk to a pain management psychologist, or pain management psychotherapist, who can help you figure out the next steps for you. This does not mean that you are ‘crazy.’ It means that you need a specialist in pain management who can work with you to find ways of managing your pain over time. We have to focus on certain medical issues here so that we can assist you as best we can. We have certain things we can do here and some we can’t. We understand how difficult this is, but…..” This helps to limit and focus the patient once they have felt they have been heard. Further tips in talking to different types of patients are available in a previous article entitled “Taxonomy of Pain Behaviors.”

10. There are times that the patient may have valid points. There may be occasions that the patient may have valid points to make about treatment by the provider or staff although they may tend to expand on the issue in reactive or dramatic ways. It is important to listen, to let them know they are heard, and to apologize if it is necessary. “Giving in” many times is a way of winning through support. Patients tend to respect those who are willing to be open, honest, and to admit to issues rather than those who are defensive. This helps to reduce their anger and upset dramatically — if done early in the discussions. However, it is first important to allow the patient to vent and be heard.

11. Use a sense of humor to lighten interactions. Being able to relax and see the humor in day-to-day interactions helps one’s perspective. Part of having a sense of humor is to be able to “laugh with the patient” rather than “at the patient.” Because patients are usually anxious about being in a professional relationship, it helps to relax them if they can sense the humor in the provider’s voice and tone. Knowing how to lighten up a situation can often loosen up the most tense person. Get help from those who do it successfully. Use them as a “humor mentor” to help learn how to be more relaxed with patients.

Conclusion

Interactions with patients are some of the more intense intimate interactions we face in life and as a result are filled with emotions that are bound to “spark” and impact us both positively and negatively. The goal of this discussion is to understand what it is that makes some interactions with patients, and providers, difficult. Knowing that all parties bring unconscious patterns to bear on provider-patient interactions allows providers to consciously review and improve their response style and interactions with patients.

Dr. Ron Lechnyr, PhD, DSW, is a Clinical Medical Psychologist, and Licensed Clinical Social Worker, in the Pain Management & Behavioral Medicine Clinic, 2440 Willamette St., Eugene, Or (344-CALM 2256). He has spent over 38 years working in coordination with physicians in medical clinics, hospitals, pain centers, and through a private practice setting. He has worked in the Mid-West and Boston, Massachusetts, followed by spending nine years working in the U.S. Public Health Service Indian Hospitals in Arizona and New Mexico, before moving to Eugene, Oregon 28 years ago. He is a board certified Diplomate in the American Academy of Pain Management, and is a Senior Fellow, Biofeedback Certification institute of America. He was also the cofounder, and Clinical Director, of the multi-disciplinary Oregon Pain Center for ten years. He is the Past-President of the Pain Society of Oregon

Terri Lechnyr, LCSW, Ph.D. is a Psychologist Resident and Licensed Clinical Social Worker who is in private practice at the Pain Management & Behavioral Medicine Clinic. Supervisor: Dr. Teri Strong.  She is also an active member of the Pain Society of Oregon.  She graduated with her Bachelors in Clinical Social Work from Pacific Lutheran University, her Masters in Clinical Social Work from Walla Walla University, and her Ph.D. in Psychology from Harold Abel School of Psychology Capella University.

References
1. Lechnyr, RJ and Holmes, HH. Taxonomy of Pain Behaviors. Practical Pain Management. September/October 2002. 2:5;18-25.

2. Lechnyr, RJ and Lechnyr, TA. Psychological Dimensions of Pain Management. Practical Pain Management. July/August, 2003. 3:4;10-18

3. Beckwith, H. What Clients Love: A Field Guide to Growing Your Business. Warner Books. NY. 2003.

4. Wainrib, B. Has Serious Illness Change Your Life? The Psychotherapy Bulletin. Summer, 1998. 33:3.

5. Michell, K. The Dance of the Invisible Impairments: Chronic Pain Syndrome and the Disability Insurer. American Pain Society Bulletin. July/August 2000. 10:4.

6. Strunin, L and Boden, L. Cool Reception for Injured Workers. American Journal of Industrial Medicine. October, 2000.

7. Sullivan M, Rogers W, and Kirsch I. Catastrophizing, Depression and Expectancies for Pain and Emotional Distress. Journal of Pain. 2000. 91:1- 2;147-154.

8. Vowles, KE and Gross, RT. Work-related beliefs about injury and physical capability for work in individuals with chronic pain. The Journal of Pain. February,
2003. 101:3;291-298.

9. Lang, RA. Primer of Psychotherapy, Gardner Press. NY. 1988.

10. Reik, T. Listening with the Third Ear: The inner Experience of a Psychoanalyst. Farrar, Straus and Company. New York. 1949.

11. Robeznieks, A. The Power of an Apology. AMANews. American Medical Association. July 25, 2003. 9-10.

12. Lechnyr, RJ. The Cost Savings of Mental Health Services. The EAP Digest. November/December, 1993. 14:1;22-27.

13. Lechnyr, RJ. Psychologists & Primary Medical Care Integration of Care, Oregon. Psychological Association Journal. November, 1999. 18:9.

14. Lechnyr, RJ. Getting to the Point: Myofascial Soft-Tissue Disorders. Practical Pain Management. November/December, 2001. 1:6;16-20.

• “Provider Patient Interactions” Download
  By Ron Lechnyr, PhD, DSW, Terri A. Lechnyr, MSW, LCSW

Impediments to Patient-Doctor Interactions

The management of chronic pain patients has been the subject of much debate over the years. The public has been concerned about inadequate pain medication prescribing for those suffering from chronic pain conditions or those who have terminal conditions and are struggling with adequate pain control during their last days. Medical licensing boards, physicians, and the Federal Drug Enforcement Administration (DEA) are concerned about inappropriate or over-prescribing, addictions to opioids, and drug diversion. This has resulted in physicians losing their license to prescribe, some physicians being jailed for prescribing opioid pain medication,1 and many physicians who are, as a result, extremely reluctant to prescribe any type of pain medication beyond the use of NSAIDs. Tensions and concerns are high among the DEA, physicians, and licensing boards. Patients respond to these tensions in negative ways by withholding information, trying to manipulate patient- Physician interactions, or by being tense and angry in interactions with providers. The American Pain Society, the International Society for the Study of Pain, and the American Academy of Pain Management, have all worked hard to change the environment and to present realistic approaches to prescribing for chronic pain patients. Pain medication prescribing is now seen as a basic patient right, but many physicians are still concerned about what this means for them as professionals and their practice. There are those who continue to have lingering suspicions that patients who are seeking pain medications are ‘drug seekers’ who only want to obtain legal prescriptions to satisfy their drug habits. To combat this, specific guidelines have been established to assist the prescribing professional working with chronic pain patients. These guidelines include a pain contract, specific documentation, follow-up, and monitoring for diversion or overuse of medications.

Complication of Managed Care

The managed care model in which the physician is the ‘gatekeeper’ of medical care has further complicated the relationship between doctors and pain patients since this model is based on limiting services, watching for ‘over-utilizers,’ and keeping the costs of care down as much as possible. As a result, physicians involved in treating chronic pain patients now feel that they must be constantly on guard for patients who will misuse services in some manner— even though only a small percentage of patients fall into this category. Even psychologists are being recruited by Independent Medical Examiner (IME) panels to detect deception and malingering rather than focusing on assisting patients in finding the most appropriate focus for care. Patients often report that they feel ‘talked down to’ and have assumptions being made about them without an attempt to understand them as individuals. These pain patients feel that medical appointments are more like interrogation sessions where they are under investigation and are dictated to about how to live and function, rather than being ‘listened too.’ This charged environment, especially in the pain patient’s case, often transforms the character of health care relationship from a relaxed atmosphere where one can feel safe in expressing fears and struggles, into a one-way dictation. Humor has often gone out of these interactions and the ‘curative factors in the professional relationship’ — central to psychological care and improvement —have been lost. This has fostered a professional relationship filled with misunderstanding, distance in relationship, and has left some physicians and patients, alike, feeling like criminals.

Social Situational Blocks

Psychological researchers have identified blocks to effective provider-client (i.e. doctor-patient) relationships and shed light on the struggles pain physicians face in providing services. Though many positive changes have happened in the field of pain management, including the importance of a multi-disciplinary approach to care, there are still blocks that often complicate the health care relationship.  Psychological research has repeatedly demonstrated that people tend to underestimate how the influence of social situations can dramatically impact their behaviors. Studies — conducted in the 1960’s and 1970’s — tested the social functioning of roles in situations with outside that similar social forces are at work, namely Drug Enforcement Association DEA, licensing boards, and the legal system, on the one hand; and the great power differential existing between doctor and patient, on the other. What both studies have demonstrated is that powerful situations can cause anyone to perpetuate cruel acts — all the while justifying their behaviors and viewing the clients as ‘the enemy’ and therefore deserving of punishment. It particularly becomes a problem when the situation is focused on specific ‘situational myths’ that identify the clients in a negative manner. This can be aggravated when one is functioning in an environment of mistrust, frustration, stress, suspicion, anxiety, fear, or concern about complying with authority. Following are brief synopses of each situational study.

Impact of Outside Authority

A series of studies by Stanley Milgram, PhD, at Yale University in the 1960’s showed the impact that outside authority can have on human behavior, in particular where it relates to a relationship of power over others. This series involved 1,000 individuals participating in role playing as either a “teacher” or “learner.” The teachers were to administer increasing electric shocks to learners (actually hired actors) for any mistakes. The teachers could hear the screams of the learners (actors) in a separate room. Dr. Milgram wanted to see if the teachers would continue to administer increasingly lethal shocks to learners when told to do so by an authority figure in a ‘white coat.’ The result was that two thirds of the teachers continued to administer shocks with increasing voltage levels — up to 480 volts— despite screams and then total silence from the other room. In all, 100 percent of the teachers — although to varying degree — were obedient to the authority figures in administering shocks to the helpless learners.

Impact of Power Differential

In 1971, Philip Zimbardo, PhD, professor of psychology at Stanford University studied the social functioning of roles where there is an enormous power differential in interactions with others. His study focused on two dozen college students who were randomly assigned to be either prison guards or prisoners in a simulated two week jail/prison setting. Dr. Zimbardo found that he had to stop the study after only six days because the prison guards became extremely abusive and angry — basing their actions on their perception of prisoners as being manipulative, trying to get away with things, and not acquiescing to their fate/role as inmates. Prisoners were isolated, stripped of clothing, bags put over their heads — among other abusive tactics — in concerted attempts to humiliate and over-control the prisoners. Anger at the prisoners was extremely high. Prisoners, responding to their treatment, became protectively manipulative and engaged in negative behaviors that was then noted by the guards and further justified retaliation. Dr. Zimbardo concluded that when the balance of power is so unequal, even normal people with no past history of psychological problems will become abusive and brutal unless extreme measures are taken to control hostile impulses. None of the students in the study had any previous pathology or problems noted prior to the study. Dr. Zimbardo further noted that when individuals are placed in alien settings, the situation itself will likely produce classic cases of abuse of power and control.

Implications for Pain Professionals

What both Zimbardo and Milgram noted is that interactional problems first start with a failure of leadership. This can include a diffusion of responsibility, dehumanization of clients, secrecy, lack of accountability, re-labeling controlling behaviors as necessary, developing justifications for controlling behaviors, social peer modeling of negative behaviors, group pressures to conform, issues related to obedience of authority, and self-protection. These studies have clear implications for pain management professionals who are treated as suspect by their peers, licensing boards, the DEA, and legal professionals. The fear of pain patients becoming addicted, or being perceived as ‘drug seeking,’ often heightens a sense of concern for how to best work with patients who present with complex health care problems. It requires that patient management programs be constructed to facilitate better interactions with the patients. Discussing potential social situational blocks openly with staff is critical to helping to reduce negative consequences in patient-provider interactions.

The following guidelines may be useful for focusing treatment efforts in the best in the best interests of both the patient and physician:

1. The recommendations about doing an adequate history, documentation, assessment, and treatment plan, along with a medication contract, should in no way reflect an assumption that all pain patients are ‘drug seekers’ who will misuse their medications. It is important to have adequate documentation with a treatment plan that also has a focus on a multi-disciplinary approach to care. The vast majority of chronic pain patients feel they have been abandoned by the medical system and do not believe that anyone will work with them to address their needs. Their initial distrust needs to be overcome with the development of a positive relationship where the patient can feel free to express their concerns along with receiving education about how to care for themselves.

2. It is critical to understand that psychological research has repeatedly demonstrated that people tend to underestimate how the influence of social situations can dramatically impact behavior. While everyone likes to think that they have full control over their own actions, certain aspects of social situations can exert powerful influences and precipitate an unwanted reaction. Most importantly, one tends to underestimate the impact of obedience to authority on one’s own behavior. In fact, even professional experts tend to underestimate how much human obedience to authority will affect an individual’s behaviors. It is critical that providers prepare themselves with preemptive guidelines and training to avoid negative behavioral patterns — due to societal and professional authority interactions with pain patients —that would otherwise have negative impacts on the doctor-patient relationship.

3. Third, the tragic situation of prisoner abuse that happened in the Iraq war at the Abu Ghraib Prison underscores how inadequate training, undefined ethical guidelines, lack of clear lines of leadership command, poor staffing patterns, and a focus on ‘the ends being more important than the means,’ all lead to negative consequences for all concerned. Following the prison abuse scandal at Abu Ghraib, new techniques were instituted focused on ‘incentive based interrogation’ based on the development of trust, respect, rapport building. These techniques are designed to insure the dignity of suspects as an integral part of relationship building with the goal of attaining more reliable information. Such lessons in relationship building in difficult circumstances should guide health care professionals’ interactions with pain patients.

4. Psychological research has shown that personality style and attitudes are basically stable over an individual’s life-span. Those who tend to be more compliant to authority will have a more difficult time making independent decisions even when they violate ethical standards. Others who are more independent thinkers tend to avoid group conformity and are less prone to blind obedience to authority. However, since there is a complex interplay between personality and social situational influence, it is difficult to fully predict future human behavior based on personality style alone. This is further complicated by the fact that humans are very quick to justify their behaviors. When there are negative consequences for behaviors resulting from peer pressure, unquestioning obedience to authority, or situational influence, most are quick to project blame on to victims and others; it is easy to shift responsibility from oneself. All of this suggests that leadership, oversight, and training all play an important role in allowing, or avoiding, abusive behaviors to happen within any setting. It is important to be aware that such behaviors can happen in any work setting/organization, and points to the need to carefully select and train supervisors because of their unique position of authority in a work setting which can cause abuse of power toward employees and customers. It also points to the need to be aware of one’s own struggles with counter-transference interactions with patients that can be influenced by the situation, peer pressure, and the patient’s transferred fears, concerns and anxieties.

CONCLUSION

Basic patient interactions require: 1) an understanding of information on how to work with patients presenting with chronic pain; 2) ‘starting where the patient is at’ rather than where the provider feels things should be focused; 3) starting interactions with patients using uncritical listening; 4) knowing the importance of a ‘nonjudgmental attitude’ in interactions with patients; 5) remembering that the most important curative factor in all therapeutic interactions is ‘the relationship.’ Without a positive, and trusting, relationship with mutual respect, little can be accomplished therapeutically, while a positive relationship can help deal with even ‘problem behaviors’ in a more open and helpful manner. This can even facilitate facilitate work with patients who present noncompliance, abuse, or other problems, since it allows the professional to work within the professional relationship to assist in resolving such dysfunctional behaviors.

Terri Lechnyr, LCSW, Ph.D. is a Psychologist Resident and Licensed Clinical Social Worker who is in private practice at the Pain Management & Behavioral Medicine Clinic. Supervisor: Dr. Teri Strong.  She is also an active member of the Pain Society of Oregon.  She graduated with her Bachelors in Clinical Social Work from Pacific Lutheran University, her Masters in Clinical Social Work from Walla Walla University, and her Ph.D. in Psychology from Harold Abel School of Psychology Capella University.

Dr. Ron Lechnyr, PhD, DSW, is a Clinical Medical Psychologist, and Licensed Clinical Social Worker, in the Pain Management & Behavioral Medicine Clinic, 2440 Willamette St., Eugene, Or (344-CALM 2256). He has spent over 38 years working in coordination with physicians in medical clinics, hospitals, pain centers, and through a private practice setting. He has worked in the Mid-West and Boston, Massachusetts, followed by spending nine years working in the U.S. Public Health Service Indian Hospitals in Arizona and New Mexico, before moving to Eugene, Oregon 28 years ago. He is a board certified Diplomate in the American Academy of Pain Management, and is a Senior Fellow, Biofeedback Certification institute of America. He was also the cofounder, and Clinical Director, of the multi-disciplinary Oregon Pain Center for ten years. He is the Past-President of the Pain Society of Oregon

(www.painsociety.com).

References

1. Robeznieks A. California Law Eases Threat to PainMedication Prescribers. American Medical News. September 14, 2004. 47:34, 1-3.

2. Morris JR. Controlled Substance and Intractable Pain: PSO Opioid Education Committee. Pain Society of Oregon. Eugene, Oregon. 2003. www.painsociety.com

3. Bender E. Opioid Analgesic Guidelines Strike Delicate Balance. Psychiatric News. October 1, 2004. 38:19, 27 & 41.

4. Derbyshire SW. If We Are to Understand Pain and Help Our Patients, What do We Need to Do Differently? American Pain Society Bulletin. September/October, 2004. 14:5, 5 & 10.

5. Landers SJ. Program helps doctors who treat addictions: The number of patients becoming addicted to narcotic pain meds outstrips the number of physicians available to treat them. American Medical News. November 1, 2004. 47:42, 25.

6. Lechnyr R J and Lechnyr TA. Psychological Dimensions of Pain Management, Practical Pain Management. July/August, 2003. 3:4, 10-18

7. Turk DC. Progress and Directions for the Agenda for Pain Management. The American Pain Society Bulletin. September/October, 2004. 14:5, 3 & 13. 8. Haney C, Banks WC, and Zimbardo PG. Interpersonal Interpersonal dynamics in a simulated prison. International Journal of Criminology and Penology, 1. 1973. 69-97.

9. Haney C and Zimbardo PG. The past and future of U.S. prison policy: Twenty-five years after the Stanford Prison Experiment. American Psychologist. 1998. 53;709-727. 10. Vocisano C, Arnow B, and Blalock J et al. Therapist Variables that predict symptom change in psychotherapy with chronically depressed outpatients. Psychotherapy: Theory, Research, Practice, Training. 2004. 41:3, 255-265.

11. Schwartz J. Simulated prison in ‘71 Showed a fine line between ‘normal’ and ‘monster.’ New York Times. May 6, 2004. p. A20.

12. Zimbardo PG. How Psychology Can Help Explain The Iraqi Prison Abuse And Work Place Stress.. The American Psychological Association, Washington, D.C. May, 2004. http://www.apa.org/pubinfo/prisonerabuse. html.

13. Zimbardo PG. A situationist perspective on the psychology of evil: Understanding how good people are transformed into perpetrators In The social psychology of good and evil. AG Miller, Ed. Guilford Press. New York. 2004. pp. 21-50.

14. Zimbardo PG, Maslach C, and Haney C. Reflections on the Stanford Prison Experiment: Genesis, transformations, consequences. In Obedience to authority: Current Perspectives on the Milgram paradigm. T. Blass, Ed. Erlbaum. Mahwah, NJ. 2000. pp.193-237.

15. Zimbardo PG. Stanford University Prison-Guard Experiment: A Simulation Study of the Psychology of Imprisonment Conducted at Stanford University. 2004. http://www.prisonexp.org.

16. Zimbardo PG. Transforming California’s prisons into expensive old age homes for felons: Enormous hidden costs and consequences for California’s taxpayers. The Center on Juvenile and Criminal Justice, San Francisco, CA. 1994.

17. Zimbardo PG. Testimony of Dr. Philip Zimbardo to U.S. House of Representatives Committee on the Judiciary. In Before the law: An introduction to the legal process, 2nd ed. J J Bonsignore, et al., Eds. Houghton Mifflin. Boston. 1979. pp. 396-399.

18. Zimbardo PG. The detention and jailing of juveniles (Hearings before U.S. Senate Committee on the Judiciary Subcommittee to Investigate Juvenile Delinquency. September, 1973). Washington, DC: U.S. Government Printing Office. 1974. pp. 141-161.

19. Zimbardo PG, Haney C, Banks WC, and Jaffe D. The mind is a formidable jailer: A Pirandellian prison. The New York Times Magazine, Section 6, 36, ff. April 8, 1973.

20. Breckler SJ. How can Science of Human Behavior help us understand Abu Ghraib: Psychological Science and Abu Ghraib. APA Congressional Science Briefing. June 10, 2004. http://www.apa.org/ppo/issues/breckler604.html.

21. Lechnyr RJ. Getting to the Point: Myofascial Soft- Tissue Disorders, Practical Pain Management. November/ December, 2001. 16-20.

22. Lechnyr RJ and Holmes HH. Taxonomy of Pain Behaviors, Practical Pain Management. September/

October, 2002. 2:5, 18-25.

23. Krane J. New Techniques Reap More Intelligence Tips. The Associated Press, reported in the Register- Guard Newspaper. Tuesday, September 7, 2004.  24. Hyer L and Kramer D. CBT with older people: Alterations and the value of the therapeutic alliance.

Psychotherapy: Theory, Research, Practice, Training.2004. 41:3, 276-291.

25. Lechnyr RJ and Lechnyr, TA. Provider-Patient Interactions: Understanding unconscious interpersonal defensive responses in a Chronic Pain Practice to Improve Interactions. Practical Pain Management.

“Pain Management Pitfalls” Download
By Ron Lechnyr, PhD, DSW, Terri A. Lechnyr MSW, LCSW