Forging Relationships with

Chronic Pain Patients

Barry Egener, MD

Transference

Countertransference

Transference: the set of expectations, beliefs, and emotional responses that a patient brings to the doctor-patient

relationship

based, at least in part, on the persistent experiences a patient has had with other important authority figures throughout his life

Transferential Responses to Illness Perception:

• Lowered self image anxiety• Threat to homeostasis denial• Failure of self-care depression,

blaming• Sense of loss of control regression,

isolation, dependency, anger

To understand the transference perceptions ask:1. How has your illness affected the way

you feel about yourself?2. Do you ever blame yourself for your

condition?3. Do you ever feel like you are losing

control?4. Are you ever afraid that you will fall

completely apart?

Counter transference: the set of expectations, beliefs, and emotional responses that a doctor brings to the doctor-patient relationship…………..Physicians often have unconscious or unspoken beliefs about the patientA “Good” Patient:• Severity of symptoms correlates with an overtly

diagnosable biological disorder• Compliant and does not challenge treatment• Emotionally controlled• Grateful

How Might These 3 Patients Present?

• 86 yo man with COPD, end-stage cardiomyopathy, ischemic foot ulcer• 51 yo woman chronic low back pain,

domestic violence victim, fibromyalgia• 33 yo addict with “complex regional

pain syndrome” after an injury to the brachial plexus after a fall from a ladder

NW Center – Egener

Physiologic

Social Psychologic

PAIN

BoundariesBeware the Monkey! Whose pain is it? I didn’t cause the pain; I’m not responsible for

the pain; I can’t “fix” the pain The patient’s anger (distress) is about him/her There is no reason to get angry at the patient.Beware Working Harder then the Patient You may be meeting your needs, not the

patient’s!

So What If Not Opioids?

• Use Yourself!– Empathy– Unconditional Positive Regard– Genuineness

• Guide a self-exploration: – How do you assess where you are right now? – What is important and meaningful in your life? – What small step are you willing to commit to to get there? – What help do you need?

• Assist with coping