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.
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Countertransference with chronic pain patient
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