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Plenary 5 farnan pain and co-dependency

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1) The document discusses codependency in physicians and how it can negatively impact their relationships with patients with chronic pain conditions. 2) Codependent physicians may have poor boundaries, be overcontrolling or needy of approval, and focus on fixing patients' problems rather than empowering them. 3) Left unaddressed, codependency can lead to burnout, boundary violations, and enable patients' unhealthy behaviors rather than motivate change. The key is for physicians to establish clear boundaries and work on their own issues through self-care, therapy, or support groups.

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Pain & Codependency in Physicians & Patients Dr. Paul Farnan Foundation Medical Excellence Vancouver March 2014

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Disclosure Disclosure I have no financial interests or affiliation with any pharmaceutical industry or manufacturer to disclose Disclaimer Views expressed are my own Acknowledgements Dr. Ray Baker, Dr. Mick Orescovich

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LEARNING OBJECTIVES • Physician Qualities & Vulnerabilities • Patients with Chronic Pain • Empathy, Compassion, Codependence? • Impacts on patients and physicians • Getting Help

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Physicians

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Plenary 5 farnan pain and co-dependency

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What is a ‘Good’ patient? ◦ Severity of symptoms correlates with an overtly diagnosable disorder ◦ Emotionally intact ◦ Compliant and doesn’t challenge ◦ Grateful i.e. – a good patient is a good fit with the Acute medical model Oreskovich

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is psychologically vulnerable and subject to strong emotions It is not surprising that physicians respond to these patients with emotions of their own. Patient with Complex Chronic Pain..

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 ‘If I work hard(er), I will be loved’ Roots of Physician Stress Explored Lynne Lamberg JAMA 1999;282:13-14

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• “To write prescriptions is easy, but to come to an understanding with people is hard” • - Franz Kafka

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Blame the drug.... or the patient? ‘Adverse selection’: the pairing of high risk patients with high risk opioid regimens.... Sullivan ‘Opioid Epidemic’

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Why does Adverse Selection occur? Physicians want to help patients in pain but have few tools other than Rx pad Patients with Mental Health & SUDs and multiple pain problems are more distressed (pain & psychological symptoms) and more persistent in demanding opioid initiation and dose increases Physicians use opioid prescriptions as a 'ticket out of the exam room' Sullivan

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Dysfunctional/alcoholic family of origin Emotionally traumatized Past episode of SUD Stimulus augmenters - deficit in hedonic tone Lack effective coping skills Dependent traits Problems with relationships  Savage 1991

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Empathy & Compassion Research • Subjective Experience • Empirical findings/Neuroscientific data

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Codependence A psychological syndrome seen in people affected by someone’s addictive/abusive behaviour Characterized by a need to meet the needs of, to fix or to control others.

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Codependent Physicians Might... • be overcontrolling, overresponsible • need others’ dependence upon them • derive self-worth from helping others • have alexithymia • avoid confrontation • feel compelled to fix others’ problems From Woititz 1983

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Codependent Physicians Might also... • feel anger when their help is ineffective • have trouble saying no • feel safest while giving • attract, be attracted to needy people • neglect own needs, feel stressed • have difficulty accepting help From Woititz 1983

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Enabling Q: What motivates the addict to recover? A: Awareness of the consequences of their behaviour What motivates your patient who has a complex disorder (with a behavioural component) to change their unhealthy behaviour?

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If you find that you have a constant need to help others….. Notice how you must keep them helpless R. Anthony ‘86

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Enabling • Failing to confront with feedback • Writing sick notes (stress leave) • Prescribing to treat emotional consequences • Failing to report (WCB, Motor vehicles) • Taking excessive responsibility • Not enforcing contracts • Continuing to supply drugs when they are doing more harm than good

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Physician at Risk?  Strong relationship with patient  Undervalued  Undersupported  Burnt out  Life Crises  Transitions

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Physician at Risk Illness of the provider Unresolved rescue fantasies Loneliness and impulse to confide The ‘special patient’ Inability to set limits Overconfidence Denial about possibility of boundary issues

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‘Universal Precautions’ It’s all about establishing defined boundaries from the outset  Treatment takes place within a structural & conceptual place defined by certain parameters  Boundaries exist to prevent harm to the patient  May also prevent harm to the physician  Doesn’t mean being defensively inflexible

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Boundaries?  Who negotiates them?  Who is primarily responsible? – ‘The onus for boundary safeguarding is primarily on the physician, him or her being the only professional on duty’

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Prevention Dependence(Codependence)? Independence(Contradependence)? Healthy Interdependence ‘Interpersonal relationships are the number one predictor of well-being’ Tal Ben-Shahar

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Summary: • codependence: a syndrome • interferes with boundaries, relationships • causes enabling rather than empowerment • sets up people for somatization, burnout • if identified is remediable • with help, we make the best docs

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• Read some literature: eg. Woititz, Cermak, Beattie • Go to some meetings: Al-Anon, CODA, ACOA • Study and practice health boundary setting (Boundaries, Cloud & Townsend) How to Stop Acting and Feeling Codependent

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• Get some good Cognitive Behavioural Therapy • Learn and practice meditation/mindfulness • Get a mentor • Schedule fun into your life Some more things that will help:

More Related Content

Plenary 5 farnan pain and co-dependency

  • 1. Pain & Codependency in Physicians & Patients Dr. Paul Farnan Foundation Medical Excellence Vancouver March 2014
  • 2. Disclosure Disclosure I have no financial interests or affiliation with any pharmaceutical industry or manufacturer to disclose Disclaimer Views expressed are my own Acknowledgements Dr. Ray Baker, Dr. Mick Orescovich
  • 3. LEARNING OBJECTIVES • Physician Qualities & Vulnerabilities • Patients with Chronic Pain • Empathy, Compassion, Codependence? • Impacts on patients and physicians • Getting Help
  • 6. What is a ‘Good’ patient? ◦ Severity of symptoms correlates with an overtly diagnosable disorder ◦ Emotionally intact ◦ Compliant and doesn’t challenge ◦ Grateful i.e. – a good patient is a good fit with the Acute medical model Oreskovich
  • 7. is psychologically vulnerable and subject to strong emotions It is not surprising that physicians respond to these patients with emotions of their own. Patient with Complex Chronic Pain..
  • 8.  ‘If I work hard(er), I will be loved’ Roots of Physician Stress Explored Lynne Lamberg JAMA 1999;282:13-14
  • 9. • “To write prescriptions is easy, but to come to an understanding with people is hard” • - Franz Kafka
  • 10. Blame the drug.... or the patient? ‘Adverse selection’: the pairing of high risk patients with high risk opioid regimens.... Sullivan ‘Opioid Epidemic’
  • 11. Why does Adverse Selection occur? Physicians want to help patients in pain but have few tools other than Rx pad Patients with Mental Health & SUDs and multiple pain problems are more distressed (pain & psychological symptoms) and more persistent in demanding opioid initiation and dose increases Physicians use opioid prescriptions as a 'ticket out of the exam room' Sullivan
  • 12. Dysfunctional/alcoholic family of origin Emotionally traumatized Past episode of SUD Stimulus augmenters - deficit in hedonic tone Lack effective coping skills Dependent traits Problems with relationships  Savage 1991
  • 13. Empathy & Compassion Research • Subjective Experience • Empirical findings/Neuroscientific data
  • 14. Codependence A psychological syndrome seen in people affected by someone’s addictive/abusive behaviour Characterized by a need to meet the needs of, to fix or to control others.
  • 15. Codependent Physicians Might... • be overcontrolling, overresponsible • need others’ dependence upon them • derive self-worth from helping others • have alexithymia • avoid confrontation • feel compelled to fix others’ problems From Woititz 1983
  • 16. Codependent Physicians Might also... • feel anger when their help is ineffective • have trouble saying no • feel safest while giving • attract, be attracted to needy people • neglect own needs, feel stressed • have difficulty accepting help From Woititz 1983
  • 17. Enabling Q: What motivates the addict to recover? A: Awareness of the consequences of their behaviour What motivates your patient who has a complex disorder (with a behavioural component) to change their unhealthy behaviour?
  • 18. If you find that you have a constant need to help others….. Notice how you must keep them helpless R. Anthony ‘86
  • 19. Enabling • Failing to confront with feedback • Writing sick notes (stress leave) • Prescribing to treat emotional consequences • Failing to report (WCB, Motor vehicles) • Taking excessive responsibility • Not enforcing contracts • Continuing to supply drugs when they are doing more harm than good
  • 20. Physician at Risk?  Strong relationship with patient  Undervalued  Undersupported  Burnt out  Life Crises  Transitions
  • 21. Physician at Risk Illness of the provider Unresolved rescue fantasies Loneliness and impulse to confide The ‘special patient’ Inability to set limits Overconfidence Denial about possibility of boundary issues
  • 22. ‘Universal Precautions’ It’s all about establishing defined boundaries from the outset  Treatment takes place within a structural & conceptual place defined by certain parameters  Boundaries exist to prevent harm to the patient  May also prevent harm to the physician  Doesn’t mean being defensively inflexible
  • 23. Boundaries?  Who negotiates them?  Who is primarily responsible? – ‘The onus for boundary safeguarding is primarily on the physician, him or her being the only professional on duty’
  • 25. Summary: • codependence: a syndrome • interferes with boundaries, relationships • causes enabling rather than empowerment • sets up people for somatization, burnout • if identified is remediable • with help, we make the best docs
  • 26. • Read some literature: eg. Woititz, Cermak, Beattie • Go to some meetings: Al-Anon, CODA, ACOA • Study and practice health boundary setting (Boundaries, Cloud & Townsend) How to Stop Acting and Feeling Codependent
  • 27. • Get some good Cognitive Behavioural Therapy • Learn and practice meditation/mindfulness • Get a mentor • Schedule fun into your life Some more things that will help: