Transference, Transference,

Countertransference, Countertransference,
Codependency S Empowerment Codependency S Empowerment
in the Treatment of Chronic Pain in the Treatment of Chronic Pain
Dan Shiode, Ph.D. and Denise Crosson, PhD Dan Shiode, Ph.D. and Denise Crosson, PhD
October 2008 October 2008
ntroduction: ntroduction:
What might this be? What might this be?
The Problem: The Problem:
Chronic pain clients can be challenging. Chronic pain clients can be challenging.
>>Presenting problem: chronic pain Presenting problem: chronic pain
iopsychosocial nature of chronic pain. iopsychosocial nature of chronic pain.
>>mplied by current definition. mplied by current definition.
ocusing on pain (content) vs. person ocusing on pain (content) vs. person. .
Therapist knowledge of S comfort with Therapist knowledge of S comfort with
chronic pain. chronic pain.
What's the goal of psychological treatment? What's the goal of psychological treatment?
Complicating ssues S Problems Complicating ssues S Problems
nclude: nclude:
Client: Client:
>> Chronic opioid use/addiction. Chronic opioid use/addiction.
>> Personality disorders. Personality disorders.
>> Past history of trauma. Past history of trauma.
>> Unresolved. Unresolved.
>> Dysfunctional family / codependency. Dysfunctional family / codependency.
Therapist: Therapist:
>> Unresolved issues/reactions (countertransference). Unresolved issues/reactions (countertransference).
>> Dysfunctional family / codependency. Dysfunctional family / codependency.
>> Chronic pain ?? Chronic pain ??
What's needed. What's needed.
>>Sometimes a client is just a client. Sometimes a client is just a client.
>>Understanding of chronic pain. Understanding of chronic pain.
>>Challenge: integration, acceptance, hope. Challenge: integration, acceptance, hope.
>>Special attention to transference, Special attention to transference,
countertransference, codependency. countertransference, codependency.
>>Empowerment: a useful tool. Empowerment: a useful tool.
What is Chronic Pain? What is Chronic Pain?
$uotations on Pain $uotations on Pain
Pain is perfect miserie, the worst Pain is perfect miserie, the worst
Of evils, and excessive, overturns Of evils, and excessive, overturns
All patience All patience. .
Nilton, Nilton, Paradise Lost Paradise Lost
t is not true that suffering ennobles the t is not true that suffering ennobles the
character, happiness does that sometimes, character, happiness does that sometimes,
but suffering, for the most part, makes men but suffering, for the most part, makes men
petty and vindictive. petty and vindictive. W. Somerset W. Somerset
Naugham Naugham. .
What is Pain? What is Pain?
Current Definition Current Definition
>>.unpleasant sensory and .unpleasant sensory and
emotional experience associated emotional experience associated
with actual or potential tissue with actual or potential tissue
damage." (!ASP, 1373). damage." (!ASP, 1373).
mportant mplications of Pain mportant mplications of Pain
Definition. Definition.
>>Pain is what the patient says it is (subjective Pain is what the patient says it is (subjective
nature). nature).
>>Psychological aspects become important. Psychological aspects become important.
>>Level of pain depends on variety of factors: Level of pain depends on variety of factors:
Nood. Nood.
Neaning of pain. Neaning of pain.
Context. Context.
>>Physical pain has emotional aspect. Physical pain has emotional aspect.
>>Emotional pain has physical aspect. Emotional pain has physical aspect.
iopsychosocial Nodel iopsychosocial Nodel
Social
Biological
Psychological
Feelings
Thoughts
Beliefs
Behavior
Medical Problems
Medication ssues
Sensation
Relationships
Cultural Values
What is Pain What is Pain --
R. Leriche, N.D., 1333, surgeon R. Leriche, N.D., 1333, surgeon
Physical pain is not a simple affair of an Physical pain is not a simple affair of an
impulse, travelling at a fixed rate along a impulse, travelling at a fixed rate along a
nerve. t is the resultant of a conflict nerve. t is the resultant of a conflict
between a stimulus S the whole individual. between a stimulus S the whole individual.
n a very short time it will convert the n a very short time it will convert the
brightest spirit into a being haunted, brightest spirit into a being haunted,
driven upon himself, thinking only of his driven upon himself, thinking only of his
disease, selfishly indifferent to everything disease, selfishly indifferent to everything
and everybody, and constantly obsessed and everybody, and constantly obsessed
by the dread of recurrent spasms of pain by the dread of recurrent spasms of pain. .
Acute vs. Chronic Pain Acute vs. Chronic Pain
>>Acute Pain Acute Pain: :
!ormal, predicted response. !ormal, predicted response.
eneficial S adaptive for person eneficial S adaptive for person -- warning. warning.
>>Chronic Pain Chronic Pain: :
Pain state that is persistent S cause cannot be Pain state that is persistent S cause cannot be
removed or otherwise treated. removed or otherwise treated.
Nay be associated with long Nay be associated with longterm incurable or term incurable or
intractable medical condition or disease. intractable medical condition or disease.
Results from altered nervous system. Results from altered nervous system.
Alarm serves little or no physiological function. Alarm serves little or no physiological function.
Chronic Pain: Clinical Course Chronic Pain: Clinical Course
(0 (06 Nonths) 6 Nonths)
Treatment for injury/pain. Treatment for injury/pain.
Hopeful, positive Hopeful, positive
ndependent ndependent
Notivated Notivated
Self Selfesteem OK esteem OK
Concerned, maybe Concerned, maybe
Slightly anxious Slightly anxious
Socially involved: Socially involved:
amily amily
riends riends
Work Work
!ot drug dependent or addicted. !ot drug dependent or addicted.
(6 Nonths or Longer) (6 Nonths or Longer)
Pain persistent, treatment helpful? Pain persistent, treatment helpful?
Less hope, doubt, depressed? Less hope, doubt, depressed?
Dependency, sick role? Dependency, sick role?
Less motivation Less motivation- -it hurts. it hurts.
Low self Low selfesteem esteem
Avoidant/fearful of pain. Avoidant/fearful of pain.
Worried S anxious Worried S anxious
Social isolation/withdrawal Social isolation/withdrawal
amily amily
riends riends
Work Workdisabled or term. disabled or term.
Drug dependent or addicted. Drug dependent or addicted.
Alcohol? Alcohol?
ONSET ACUTE PAIN CHRONIC PAIN
Chronic Pain: Chronic Pain:
Related Causes S Effects Related Causes S Effects
Trauma
Tension
Drug
addiction
llness
Bodily
njury
Surgery
Loneliness
Depression
Loss
PAN
Source: Doleys & Olson, 1997
Psychological Profile of Psychological Profile of
Chronic Pain Clients Chronic Pain Clients
>>Psychological factors found in at least Psychological factors found in at least
7S% of chronic pain patients. 7S% of chronic pain patients.
>>Depression more likely to result from Depression more likely to result from
pain rather than cause chronic pain. pain rather than cause chronic pain.
>>Psych factors interfere with ability to Psych factors interfere with ability to
differentiate pain from anxiety, differentiate pain from anxiety,
depression or other psych symptoms. depression or other psych symptoms.
Source: Doleys & Olson, 1997
Key Psychological actors Key Psychological actors
>>Key psych factors include: Key psych factors include:
Nood disorders (anxiety, depression). Nood disorders (anxiety, depression).
Personality traits: tendency to be anxious, Personality traits: tendency to be anxious,
depressed, or focused on somatic complaints depressed, or focused on somatic complaints
(Nanchikanti, et al, 2002). (Nanchikanti, et al, 2002).
Personality disorders. Personality disorders.
Sleep disorders. Sleep disorders.
Dependency (major issue). Dependency (major issue).
Doleys & Olson, 1997
Psychological Profile of Psychological Profile of
Chronic Pain Clients, cont'd. Chronic Pain Clients, cont'd.
>>Psychologically normal" patients more likely to Psychologically normal" patients more likely to
respond positively to pain treatment. respond positively to pain treatment.
>>Patients with significant psychological factors Patients with significant psychological factors
(type P and ) tend to respond poorly to pain (type P and ) tend to respond poorly to pain
treatment. treatment.
>>Chronic pain clients rarely attempt to Chronic pain clients rarely attempt to
misrepresent pain as real misrepresent pain as real -- when they do, it is when they do, it is
usually for monetary gain. usually for monetary gain.
NNP NNP2 P 2 PA A ! Sub ! SubCroups Croups
>>P": Nost pathological, general elevation P": Nost pathological, general elevation
profile. profile.
>>A": Nost prevalent (about 30%), A": Nost prevalent (about 30%),
conversion v" profile, post conversion v" profile, postmorbid" morbid"
profile. profile.
>>" : Second most prevalent, D" up more, " : Second most prevalent, D" up more,
neurotic triad" profile. neurotic triad" profile.
>>!": !ormal !": !ormallimits profile. limits profile.
Source: Costello (1387). Source: Costello (1387).
Type P
50
70
48
82
88
80
77
60
70
78
81
65
60
40
65
90
L F K Hs D Hy Pd Mf Pa Pt Sc Ma Si
MMPI-2 ScaIes
T
-
s
c
o
r
e
s
Type A
51 51
55
75
1
75
0
50
58
59
1
2
48
40
65
90
L F K Hs D Hy Pd Mf Pa Pt Sc Ma Si
HHP| -2 8ca|es
T
-
s
c
o
r
e
s
%50
51
60
55
85
78
80
60
57
56
66
64
55 55
40
65
90
L F K Hs D Hy Pd Mf Pa Pt Sc Ma Si
MMPI-2 ScaIes
T
-
s
c
o
r
e
s
Type N
51
50
55
2
0
2
55
54 54
5
54
55
52
40
65
90
L F K Hs D Hy Pd Mf Pa Pt Sc Ma Si
MMPI-2 ScaIes
T
-
s
c
o
r
e
s
AII Types
40
65
90
L F K Hs D Hy Pd Mf Pa Pt Sc Ma Si
MMPI-2 ScaIes
T
-
s
c
o
r
e
s
Type P
Type A
Type |
Type N
Psychological Testing Psychological Testing --
Useful Adjunct Useful Adjunct
>>NNP NNP22
>>NCN NCN
>>NcCill Pain $uestionnaire (NP$) NcCill Pain $uestionnaire (NP$)
>>Coping Skills $uestionnaire (CS$) Coping Skills $uestionnaire (CS$)
>>Nultidimensional Pain nventory (NP) Nultidimensional Pain nventory (NP)
>>eck Depression nventory eck Depression nventory
Chronic Pain Chronic Pain Client Presentations Client Presentations
>> Adaptive coper, strong, athletic, anti Adaptive coper, strong, athletic, antisick role. sick role.
>> Passive Passivedependent, victimized/weak, sick role. dependent, victimized/weak, sick role.
>> People pleaser: focused on others. People pleaser: focused on others.
>> Depressive self Depressive selfhater: self hater: selfdirected anger. directed anger.
>> Passive Passiveaggressive, acting out indirectly. aggressive, acting out indirectly.
>> Silently suffering. Silently suffering.
>> Seeking pain cure only no psych issues". Seeking pain cure only no psych issues".
>> Chronic pain client with borderline traits. Chronic pain client with borderline traits.
>> Chronic pain client with narcissistic traits. Chronic pain client with narcissistic traits.
>> Ceneral elevation profile (multiple psych symptoms). Ceneral elevation profile (multiple psych symptoms).
>> Addicted / denies addiction / dependent / on fence. Addicted / denies addiction / dependent / on fence.
>> Desperately seeking treatment S relief. Desperately seeking treatment S relief.
Chronic Pain Patients: Chronic Pain Patients:
Possible Presentations Possible Presentations
Primary Problem Primary Problem Secondary Problem Secondary Problem Tertiary Problem Tertiary Problem
Chronic pain (CP) Chronic pain (CP) !one/Denied. !one/Denied. !one. !one.
CP CP Psychological Psychological !one. !one.
CP CP Psychological Psychological Addiction/Dependence Addiction/Dependence
Psychological Psychological CP CP !one/denied. !one/denied.
CP CP Addiction/Dependence Addiction/Dependence Psychological Psychological
Addiction/Dependence Addiction/Dependence CP CP Psychological Psychological
What is Transference? What is Transference?
Source: Greenacre(1954)
Transference Transference -- Psychoanalytic Psychoanalytic
>>Patient re Patient reenacts with psychotherapist enacts with psychotherapist
experiences/issues from early relationships. experiences/issues from early relationships.
>>Therapist is main figure of significance, Therapist is main figure of significance,
reacted to as if person from the past. reacted to as if person from the past.
>>Repetition: new edition of old object Repetition: new edition of old object
relationship. relationship.
>>Safeguarding S analyzing transference Safeguarding S analyzing transference
relationship is of prime importance". relationship is of prime importance".
Source: Shapiro(1989)
Transference Transference -- Psychodynamic Psychodynamic
>>Attitudes S reactions toward the therapist. Attitudes S reactions toward the therapist.
>>Ways in which the patient doesn't talk Ways in which the patient doesn't talk
straight" straight"- -distorts communication S distorts communication S
engages in self engages in selfdeception. deception.
>>Therapist is object of communication, Therapist is object of communication,
subject of neurotic conflict S concern. subject of neurotic conflict S concern.
>>Dynamics of personality brought into office Dynamics of personality brought into office
S are engaged by the relationship. S are engaged by the relationship.
>>A way of being, after all, is a way of A way of being, after all, is a way of
relating". relating".
The Coal of Therapy The Coal of Therapy
Psychodynamic Psychodynamic
>> Psychotherapy does not aim directly to increase self Psychotherapy does not aim directly to increase self
esteem, but to diminish shame, esteem, but to diminish shame,
>> .|aims to] increase interest in life by.diminishing the .|aims to] increase interest in life by.diminishing the
subjective distress S preoccupation with self that interfere subjective distress S preoccupation with self that interfere
with interest in life. with interest in life.
>> .aims to diminish .the self .aims to diminish .the selfestrangement that is a estrangement that is a
consequence of that reaction.|and] to enlarge the realm consequence of that reaction.|and] to enlarge the realm
of self of selfdirection S autonomy." direction S autonomy."
Shapiro (1383), p. 116 Shapiro (1383), p. 116
Source: Wright, et al (2005)
Transference TransferenceCT CT
>> Reenacting key elements of previously important Reenacting key elements of previously important
relationships. relationships.
>> Habitual ways of thinking S acting.recapitulated in Habitual ways of thinking S acting.recapitulated in
treatment." treatment."
>> Look for schemas S behavioral patterns in therapeutic Look for schemas S behavioral patterns in therapeutic
relationship that may have developed in past relationships. relationship that may have developed in past relationships.
>> mportance is potential effects on patient's core beliefs S mportance is potential effects on patient's core beliefs S
behavior, S if interferes with goals of treatment. behavior, S if interferes with goals of treatment.
Transference ehavior Transference ehavior examples examples
>> Strong feelings of attraction or revulsion (e.g., Strong feelings of attraction or revulsion (e.g.,
sexual attraction, admiration). sexual attraction, admiration).
>> Asking questions about the therapist's private life. Asking questions about the therapist's private life.
>> Preferring one therapist/staff over another. Preferring one therapist/staff over another.
>> Sitting next to/away from counselor in group. Sitting next to/away from counselor in group.
>> Trying hard to please the therapist Trying hard to please the therapist- -being best being best
patient, taking notes. patient, taking notes.
>> Acting as if is favorite client". Acting as if is favorite client".
>> Acting out (e.g., not doing assignments, bulimia, Acting out (e.g., not doing assignments, bulimia,
poor attendance, being constantly late). poor attendance, being constantly late).
Countertransference (CT) Countertransference (CT)
Source: Masterson(2000); Shapiro(1989)
Countertransference (CT) Countertransference (CT)
>>All those emotions in the therapist that All those emotions in the therapist that
interfere with the ability to provide a interfere with the ability to provide a
therapeutically neutral frame" (Nasterson) therapeutically neutral frame" (Nasterson)
>>Therapist's undesirable" reactions to the Therapist's undesirable" reactions to the
client's attitudes, values, behaviors, etc. client's attitudes, values, behaviors, etc.
>>How therapist doesn't talk straight" How therapist doesn't talk straight"
(Shapiro, Kaiser). (Shapiro, Kaiser).
>>ased on therapist's conflicts, experiences, ased on therapist's conflicts, experiences,
or issues related to past relationships or issues related to past relationships
Source: Kernberg(2000)
CT with orderline Clients (Kernberg) CT with orderline Clients (Kernberg)
>>Defends by trying to take control of you through Defends by trying to take control of you through
hatred S punishment, projects rage or hatred. hatred S punishment, projects rage or hatred.
>>Concordant CT": feeling same as patient. Concordant CT": feeling same as patient.
>>Complimentary CT": identification with object Complimentary CT": identification with object
not tolerated by patient. not tolerated by patient.
!eed to understand client object relations. !eed to understand client object relations.
>>ut remember ut remember it's not really you it's not really you. .
Source: Kernberg(2000)
Working with CT antasies S eelings Working with CT antasies S eelings
(Kernberg) (Kernberg)
>>Allow CT fantasy/feeling to be conscious Allow CT fantasy/feeling to be conscious
((not acted out not acted out) S analyzed ) S analyzed
helps to understand devalued object S create a helps to understand devalued object S create a
transference interpretation. transference interpretation.
>>ecomes a cognitive ecomes a cognitiveemotional (corrective) emotional (corrective)
experience for client. experience for client.
>>%equires good boundaries S limits %equires good boundaries S limits, especially , especially
with borderline or narcissistic patients. with borderline or narcissistic patients.
Possible CT Reactions with Possible CT Reactions with
Chronic Pain Clients Chronic Pain Clients
>> ascination (too engrossed in content, experiences). ascination (too engrossed in content, experiences).
Nay miss important data or meaning of behavior/reactions. Nay miss important data or meaning of behavior/reactions.
>> Overly focused on the pain (content). Overly focused on the pain (content).
E.g., enables avoidance of feelings/acceptance/moving on. E.g., enables avoidance of feelings/acceptance/moving on.
>> Avoiding topics (e.g., medication overuse, addiction) Avoiding topics (e.g., medication overuse, addiction)
Nay depend on orientation. Nay depend on orientation.
>> Taking their side (to be liked). Taking their side (to be liked).
dentifying with projections ?? dentifying with projections ??
>> Abhorrence Abhorrence -- repressed or denied. repressed or denied.
>> Attraction. Attraction.
>> Anger or intense frustration. Anger or intense frustration.
Codependency Codependency
Source: Baker(2008); Pohl(2008)
Codependence Defined Codependence Defined
>> Phenomenon seen in people affected by other person's dysfunctional Phenomenon seen in people affected by other person's dysfunctional
behavior. behavior.
>> Characteristics: Characteristics:
"Other "Othercentered" centered"- -overly focused on other vs. self. overly focused on other vs. self.
Unhealthy need to meet other person's needs, fix or control others. Unhealthy need to meet other person's needs, fix or control others.
Co Codependent person usually considered to be enabler. dependent person usually considered to be enabler.
Drug of choice" = addict/dysfunctional person. Drug of choice" = addict/dysfunctional person.
>> ey ey: : protects partner from natural consequences of behavior protects partner from natural consequences of behavior..
>> 'm OK only if you're OK" (Pohl, 2008). 'm OK only if you're OK" (Pohl, 2008).
>> sefulness sefulness: helps to recognize, understand S predict behavior of : helps to recognize, understand S predict behavior of
patients with complex problems. patients with complex problems.
Source: Baker(2008); Pohl(2006)
Development of Codependency Development of Codependency
>>Child born into dysfunctional family system. Child born into dysfunctional family system.
!ot all become codependent. !ot all become codependent.
>>Addict: Addict:
Trying to fix something inside with drug. Trying to fix something inside with drug.
Access to emotions blocked, so no emotional Access to emotions blocked, so no emotional
intimacy because can't feel (Pohl, 2006). intimacy because can't feel (Pohl, 2006).
CP client may end up in similar position. CP client may end up in similar position.
>>Enabler: Enabler:
Other Othercentered, tries to fix/control addict. centered, tries to fix/control addict.
Addicted" to addict. Addicted" to addict.
>>Child attachment S other needs may not Child attachment S other needs may not
be met. be met.
Source: Baker(2008)
Dysfunctional amily Systems Dysfunctional amily Systems
>>unction in bizarre but functional ways. unction in bizarre but functional ways.
What does child learn from watching/interacting with What does child learn from watching/interacting with
addicted S enabling parents? addicted S enabling parents?
>>Spoken/unspoken rules in family may be good Spoken/unspoken rules in family may be good
adaptation (e.g., survival behavior). adaptation (e.g., survival behavior).
>>ehaviors learned may benefit later (e.g., reading ehaviors learned may benefit later (e.g., reading
people well, empathy/compassion). people well, empathy/compassion).
Cood psychotherapy skills? Cood psychotherapy skills?
Source: Baker(2008)
Dysfunctional amily Systems Dysfunctional amily Systems --
Examples of amily Rules Examples of amily Rules
>>Secrets Secretsnot allowed to discuss. not allowed to discuss.
>>Truth is bendable. Truth is bendable.
OK to lie about addict's behavior. OK to lie about addict's behavior.
Precursor to cognitive distortions. Precursor to cognitive distortions.
>>Promises get broken. Promises get broken.
>>Emotions not allowed or should be muted. Emotions not allowed or should be muted.
Attachment needs may not be met. Attachment needs may not be met.
>>The rules will likely change. The rules will likely change.
Source: Baker(2008)
Precursor to Chronic llness/Pain?? Precursor to Chronic llness/Pain??
>> Alexithymia (can't read my feelings): Alexithymia (can't read my feelings):
A" = without" A" = without"
lex" = read" lex" = read"
thymia" = feelings" thymia" = feelings"
>> Learning to turn emotions S needs off (dysfunctional Learning to turn emotions S needs off (dysfunctional
family system). family system).
>> When physical illness occurs, child shown caring, given When physical illness occurs, child shown caring, given
medical treatment (reward). medical treatment (reward).
>> Nay express some emotional needs or feelings into Nay express some emotional needs or feelings into
physical illness or sensations. physical illness or sensations.
>> Could complicate treatment of CP clients. Could complicate treatment of CP clients.
Source: Baker(2008)
Possible Child Roles in Possible Child Roles in
Dysfunctional amily System (can shift roles) Dysfunctional amily System (can shift roles)
>>Problem solver: Problem solver:
runs the group", people pleaser. runs the group", people pleaser.
Takes responsibility S blame for everything S others. Takes responsibility S blame for everything S others.
Tries to fix family S always in the middle. Tries to fix family S always in the middle.
Turns off own feelings, needs, for others. Turns off own feelings, needs, for others.
Develop chronic pain or illness (e.g., N)? Develop chronic pain or illness (e.g., N)?
>>Scapegoat/Problem child: Scapegoat/Problem child:
disrupts the group", identified patient. disrupts the group", identified patient.
Symbol of family problem. Symbol of family problem.
Nost likely to get intervention/treatment. Nost likely to get intervention/treatment.
Source: Baker(2008)
Possible Child Roles, continued Possible Child Roles, continued
>>Lost child: Lost child:
Hard to treat, gets lost in crowd/milieu, sitting there Hard to treat, gets lost in crowd/milieu, sitting there
spaced out. spaced out.
Coes through life invisible, withdraws/isolates. Coes through life invisible, withdraws/isolates.
Can go missing without being noticed. Can go missing without being noticed.
Likes Xanax. Likes Xanax.
>>]okster": ]okster":
Pretends everything's OK. Pretends everything's OK.
Senses problems, pushes away with jokes. Senses problems, pushes away with jokes.
Always being funny, problem getting serious. Always being funny, problem getting serious.
Source: Baker(2008)
Possible Child Roles Possible Child RolesCommonalities Commonalities
>>Child becomes focused on self: Child becomes focused on self:
'm the problem" (problem solver) 'm the problem" (problem solver)
need to fix it" (problem solver) need to fix it" (problem solver)
can't be helped" (lost child) can't be helped" (lost child)
ocus on me" (problem child) ocus on me" (problem child)
>>Distorted sense of boundaries (poor object Distorted sense of boundaries (poor object
relations). relations).
>>Nay relate to others on basis of family roles Nay relate to others on basis of family roles
S rules (transference). S rules (transference).
Dysfunctional amily Systems Dysfunctional amily Systems --
oundary ssues oundary ssues
>>oundary violations can include: oundary violations can include:
verbal, physical or sexual abuse. verbal, physical or sexual abuse.
Promises broken. Promises broken.
Lying, lying by omission. Lying, lying by omission.
!eeds for attachment, dependency S exploration not !eeds for attachment, dependency S exploration not
met. met.
Over indulgence. Over indulgence.
nconsistent rules S consequences. nconsistent rules S consequences.
Acting out condoned or lied about Acting out condoned or lied about
>>Substance or other abuse. Substance or other abuse.
>>ncludes silence or punishment for reporting/asking. ncludes silence or punishment for reporting/asking.
Source: Wood (2008)
]apanese Cultural values ]apanese Cultural values --
Codependence or !ormal" ehavior? Codependence or !ormal" ehavior?
>> On On: : implicit indebtedness" to one's parents for giving life, implicit indebtedness" to one's parents for giving life,
nurturance S socializing. nurturance S socializing.
Transferred to other relationships. Transferred to other relationships.
>> Ciri: Ciri: social obligation", ethical imperative to behave as social obligation", ethical imperative to behave as
expected by society. expected by society.
Shame used liberally to enforce this. Shame used liberally to enforce this.
>> Reciprocity: Reciprocity: at core of ]apanese behavior patterns at core of ]apanese behavior patterns -- people people
are good or bad in light of relationships with others. are good or bad in light of relationships with others.
face" face" and never and neverending gift giving ritual. ending gift giving ritual.
Codependence, Transference S Codependence, Transference S
Countertransference Countertransference
Source: Baker(2008)
Codependence S Transference: Codependence S Transference:
Effect of Rules S Dysfunctional amily Effect of Rules S Dysfunctional amily
>> Re Reenact by over enact by overcontrolling if unsafe family controlling if unsafe family
environment (safety, protection). environment (safety, protection).
>> Relate to therapist on basis of family role (e.g., running Relate to therapist on basis of family role (e.g., running
group in milieu). group in milieu).
>> Couldn't trust parents Couldn't trust parents- -may have trouble trusting may have trouble trusting
therapist (e.g., hide things). therapist (e.g., hide things).
>> Nay expect rules to keep changing, or therapist to be Nay expect rules to keep changing, or therapist to be
rigidly authoritarian (reaction to rules). rigidly authoritarian (reaction to rules).
>> Cognitive distortions: misconstrue meanings of feedback Cognitive distortions: misconstrue meanings of feedback
or interpretations (either great or no damn good"). or interpretations (either great or no damn good").
Source: Baker(2008)
Codependence S Transference: Codependence S Transference:
eelings S oundaries eelings S oundaries
>> f trouble feeling emotions, focus on physical symptoms (i.e., pain). f trouble feeling emotions, focus on physical symptoms (i.e., pain).
Resist or avoid connecting feelings to pain" or emotional pain". Resist or avoid connecting feelings to pain" or emotional pain".
Reward" therapist for staying focused on pain. Reward" therapist for staying focused on pain.
Avoid increasing intensity of therapy (e.g., less frequent visits). Avoid increasing intensity of therapy (e.g., less frequent visits).
>> f have belief that feelings aren't acceptable, may avoid expressing f have belief that feelings aren't acceptable, may avoid expressing
feelings S show resistance". feelings S show resistance".
>> f alexithymia, may not have ability to label feelings. f alexithymia, may not have ability to label feelings.
Answering how do you feel" with thoughts. Answering how do you feel" with thoughts.
>> oundary problems (e.g., personality disorders): either maintain oundary problems (e.g., personality disorders): either maintain
distance (avoid intimacy) or push for increased intensity S frequency distance (avoid intimacy) or push for increased intensity S frequency
of contact. of contact.
Demanding, urgent phone calls. Demanding, urgent phone calls.
Source: Baker(2008)
Codependence S Countertransference (CT): Codependence S Countertransference (CT):
Ray aker, N.D. Ray aker, N.D.
>> Those from alcoholic family systems are attracted to the Those from alcoholic family systems are attracted to the
healthcare profession like lemmings to the sea". healthcare profession like lemmings to the sea".
Nore other Nore othercentered" by nature. centered" by nature.
>> f you find that you have a constant need to help others, f you find that you have a constant need to help others,
notice how you keep them helpless." notice how you keep them helpless."
Doctors sometime hold their patients hostage. Doctors sometime hold their patients hostage.
oundary issue. oundary issue.
>> We want our patients to love us We want our patients to love us
Nay not ask tough questions (i.e., about addiction). Nay not ask tough questions (i.e., about addiction).
Source: Baker(2008)
Codependence S Countertransference, cont'd. Codependence S Countertransference, cont'd.
>> Codependence distorts therapeutic relationship S Codependence distorts therapeutic relationship S
communication. communication.
>> Codependence causes therapist to be an enabler vs. Codependence causes therapist to be an enabler vs.
empowering clients. empowering clients.
>> urn out with clients is a boundary problem (not a noble urn out with clients is a boundary problem (not a noble
thing). thing).
>> !ot recognizing boundaries + position of power !ot recognizing boundaries + position of power
(doctor") = more likely to overstep them. (doctor") = more likely to overstep them.
Dual relationships, outside contact, confidentiality. Dual relationships, outside contact, confidentiality.
Trap": rescuing a client (victim), anger/blame. Trap": rescuing a client (victim), anger/blame.
What to do? What to do?
>>Characteristics that increase the odds of problems Characteristics that increase the odds of problems
with CT and codependency with CT and codependency
ear (client suicide ear (client suicide inadequate training) inadequate training)
Anger/Hate (towards client) Anger/Hate (towards client)
Attraction (Pope S Tabachnick, 1333) Attraction (Pope S Tabachnick, 1333)
>>Characteristics that protect therapists from CT and Characteristics that protect therapists from CT and
codependency: codependency:
Self Selfintegration: sound character structure integration: sound character structure
Anxiety management Anxiety management
Conceptual skills: ability to draw on theory Conceptual skills: ability to draw on theory
Empathy: !OT sympathy or revulsion Empathy: !OT sympathy or revulsion
Self Selfinsight: more awareness of thoughts and feelings insight: more awareness of thoughts and feelings
gives more control over behaviors that skew the gives more control over behaviors that skew the
relationship (Hayes et al, 1331) relationship (Hayes et al, 1331)
What to do, cont'd: What to do, cont'd:
>> Remember: Remember: Pain clients are like any other client Pain clients are like any other client. .
>> e aware of biopsychosocial aspects of the patient's chronic pain e aware of biopsychosocial aspects of the patient's chronic pain
condition, but don't get lost in it. condition, but don't get lost in it.
ncrease your knowledge of chronic pain, addictions. ncrease your knowledge of chronic pain, addictions.
>> Assess for addiction in patient S family, unresolved childhood Assess for addiction in patient S family, unresolved childhood
issues or trauma, codependent traits. issues or trauma, codependent traits.
>> eep clear boundaries with ALL clients eep clear boundaries with ALL clients. .
f it feels wrong, it probably is f it feels wrong, it probably is find out why. find out why.
>> e aware of HOW clients are interacting with you, especially if it e aware of HOW clients are interacting with you, especially if it
feels odd (positive or negative). feels odd (positive or negative).
>> DO!'T CO T ALO!E: talk about your reactions S feelings with DO!'T CO T ALO!E: talk about your reactions S feelings with
supervisors or co supervisors or coworkers, psychotherapy for your own issues. workers, psychotherapy for your own issues.
What does this say? What does this say?
!ANNOWHE%E !ANNOWHE%E
Case Examples Case Examples
Case #1: Adaptive Coper Case #1: Adaptive Coper
>>]enn", a 40 ]enn", a 40year old female, work injury to low year old female, work injury to low
back, chronic LP, good relationship. back, chronic LP, good relationship.
Prior surgeries, PT multiple times, disabled. Prior surgeries, PT multiple times, disabled.
Prescribed opioids that increase function, no signs of Prescribed opioids that increase function, no signs of
addiction, underutilizes addiction, underutilizes sister was addicted to opiates. sister was addicted to opiates.
Presents positive attitude, strength, pushes. Presents positive attitude, strength, pushes.
Tends to hide emotions Tends to hide emotions- -sees as weakness (trauma). sees as weakness (trauma).
ackground in athletics. ackground in athletics.
PP=8/10, constant, shooting, burning. PP=8/10, constant, shooting, burning.
n workers compensation system. n workers compensation system.
Case #1, continued Case #1, continued
>>Problems: Problems:
Client too focused on curing the chronic pain. Client too focused on curing the chronic pain.
!eeds to accept pain as chronic S accommodate to live !eeds to accept pain as chronic S accommodate to live
better. better.
>>Transference: Transference:
rom prior trauma, projects expectations, hides feelings. rom prior trauma, projects expectations, hides feelings.
Avoids increased dependence on therapist (distances). Avoids increased dependence on therapist (distances).
>>Countertransference: Countertransference:
attraction to strong" presentation. attraction to strong" presentation.
Desire to help or rescue (enable focus on pain) vs. Desire to help or rescue (enable focus on pain) vs.
realizing need to accept S accommodate CP, to move realizing need to accept S accommodate CP, to move
on with life (e.g., enlarge autonomy"). on with life (e.g., enlarge autonomy").
Case #2: Passive Case #2: PassiveDependent Dependent
>>]ames", 48 year old male, suffered work injury ]ames", 48 year old male, suffered work injury
several years ago, multiple surgeries, disabled several years ago, multiple surgeries, disabled
from working. from working.
High level of pain reported. High level of pain reported.
Passive Passiveaggressive behavior, depressed, including aggressive behavior, depressed, including
suicide attempt. suicide attempt.
High level of opiate pain medication use. High level of opiate pain medication use.
>>Developed tolerance S dependence. Developed tolerance S dependence.
>>Addicted, but rejects this idea. Addicted, but rejects this idea.
Receiving pain injections that do benefit him. Receiving pain injections that do benefit him.
Narital discord, spouse enables indirectly. Narital discord, spouse enables indirectly.
n workers compensation system. n workers compensation system.
Case #2, continued Case #2, continued
>>Problems: Problems:
very fearful of pain, focused on symptom relief. very fearful of pain, focused on symptom relief.
Nanipulative S codependent: He complains, spouse Nanipulative S codependent: He complains, spouse
responds by controlling, rescuing. responds by controlling, rescuing.
>>Transference: Transference:
Passive Passivedependent, sick role, splitting. dependent, sick role, splitting.
Uses spouse to protect self, resist change. Uses spouse to protect self, resist change.
Re Reenacts focus on physical symptom vs emotional enacts focus on physical symptom vs emotional
issues or problems. issues or problems.
>>Countertransference (CT): Countertransference (CT):
Anger S frustration at being manipulated. Anger S frustration at being manipulated.
Distracted by spouse's behavior. Distracted by spouse's behavior.
lack hole" in staff meetings. lack hole" in staff meetings.
Possible CT Reactions Possible CT Reactions
>>ascination (can get too engrossed in content, ascination (can get too engrossed in content,
miss important data). miss important data).
E.g., too much focus on the pain (as content). E.g., too much focus on the pain (as content).
>>Taking their side (to be liked). Taking their side (to be liked).
>>Abhorrence Abhorrence -- repressed or denied. repressed or denied.
>>Attraction. Attraction.
>>Anger or intense frustration. Anger or intense frustration.
>>Having to prove my point. Having to prove my point.
>>eing too passive or quiet. eing too passive or quiet.
Empowerment Empowerment
Empowerment Empowerment
As first defined by Solomon (1376), empowerment involves As first defined by Solomon (1376), empowerment involves
facilitating the clients' connection with their own power facilitating the clients' connection with their own power
and, in turn, being empowered by the very act of reaching and, in turn, being empowered by the very act of reaching
across cultural barriers. across cultural barriers.
Empowerment refers to the person's ability to do for Empowerment refers to the person's ability to do for
themselves while advocacy implies doing for the client. themselves while advocacy implies doing for the client.
Even in the act of advocacy, therapists must be careful not Even in the act of advocacy, therapists must be careful not
to impose their values on clients and must seek to to impose their values on clients and must seek to
understand what clients mean, want, expect and can understand what clients mean, want, expect and can
accept as advocacy. accept as advocacy.
Respectful collaboration needs to take place to promote Respectful collaboration needs to take place to promote
mutually agreed mutually agreedon goals for change. on goals for change.
Client Empowerment Client Empowerment
Refers to the therapeutic use of the clients own essential Refers to the therapeutic use of the clients own essential
power. power.
This power can be conceptualized and thought about as This power can be conceptualized and thought about as
occurring in 4 dimensions occurring in 4 dimensions
ntellectual ntellectual
Emotional Emotional
Social Social
Spiritual Spiritual
Dimensions are listed in the order in which we generally Dimensions are listed in the order in which we generally
value ourselves and others in this culture. value ourselves and others in this culture.
Chronic Pain and Empowerment Chronic Pain and Empowerment
Chronic pain can result in enormous losses in all 4 Chronic pain can result in enormous losses in all 4
dimensions. Nost commonly: dimensions. Nost commonly:
ntellectual: Cognitive impairment (temporary or ntellectual: Cognitive impairment (temporary or
permanent), obsessive thoughts permanent), obsessive thoughts
Emotional: Substantial damage to self Emotional: Substantial damage to selfimage, increased image, increased
likelihood of unaddressed and unresolved trauma likelihood of unaddressed and unresolved trauma
Social: Damage to important relationships, Cuilt and Social: Damage to important relationships, Cuilt and
shame regarding inability to fulfill normal" role shame regarding inability to fulfill normal" role
Spiritual: Loss of hope and loss of connection to Spiritual: Loss of hope and loss of connection to
spiritual life spiritual life
Therapeutic Approach Therapeutic Approach
n the face of these losses empowering clients requires n the face of these losses empowering clients requires
that we consider the differences between: that we consider the differences between:
What we have What we have
What we do What we do
Who and what we are Who and what we are
Client Empowerment in Chronic Client Empowerment in Chronic
Pain Pain
Empowerment is important in the face of Empowerment is important in the face of
these losses but is tricky in chronic pain and these losses but is tricky in chronic pain and
common co common co- -occurring psychopathology occurring psychopathology
since it requires that we empower the since it requires that we empower the
person without enabling the disease(s). person without enabling the disease(s).
Sometimes the line between empowering and Sometimes the line between empowering and
enabling is easy to see and other times it is enabling is easy to see and other times it is
not. not.
How do we empower? How do we empower?
f the power, in empower, is f the power, in empower, is 70, 70, the the
clients own power how do we clients own power how do we
"empower the client "empower the client
%he power is not ours to give, it %he power is not ours to give, it
belongs to the client, is part of who belongs to the client, is part of who
they are so.. they are so..
What is our role? What is our role?
mportant Assumptions mportant Assumptions
!erhaps it is more useful to think of !erhaps it is more useful to think of
empowering as something the client empowering as something the client
has lost that we help them find using has lost that we help them find using
their own values, resources, and their own values, resources, and
orientation. orientation.
Clinically it is as different as giving a Clinically it is as different as giving a
person your child versus helping them person your child versus helping them
find their own lost child. find their own lost child.
Cartography and Assumptions Cartography and Assumptions
>>What's the most important thing you need What's the most important thing you need
to know to get to Chicago? to know to get to Chicago?
>>We seldom assume, as clinicians, that We seldom assume, as clinicians, that
clients are where we are clients are where we are
>>ut we often assume that the goal is to ut we often assume that the goal is to
move them in that direction move them in that direction
Client perception of received Client perception of received
wisdom wisdom
The client, on some level, understands that The client, on some level, understands that
we are trying to turn them in to who we are we are trying to turn them in to who we are
or who we think they should be. or who we think they should be.
What does this say about who we think they What does this say about who we think they
are at their most essential level? What does are at their most essential level? What does
this say about how we see them? this say about how we see them?
Alternatives? Alternatives?
Examine our own beliefs and seek to Examine our own beliefs and seek to
empower our clients rather than empower our clients rather than
repair them or redesign them in our repair them or redesign them in our
image. image.
Do believe, as a helper, that all Do believe, as a helper, that all
healthy happy people are exactly the healthy happy people are exactly the
same? Do they think, act, value, love same? Do they think, act, value, love
and fear the same things? and fear the same things?
References References
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References, cont'd References, cont'd
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%hank you for your attention.
.any questions?