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Provider-patient Interactions

Understanding unconscious interpersonal defensive responses in a chronic pain practice to improve interactions.
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Have you ever noticed that some people bring out the worst in you? Have you ever found yourself being defensive, reactive, tense, authorative, controlling, upset, confused, lost, or felt incompetent or vulnerable? Have you experienced blocks to effective treatment that seem to be “connected to something” but hard to figure out? Many articles have focused on patient psycho-pathology and issues while forgetting issues that the provider brings to the professional interaction. Perhaps something in the “psychological unspoken, unconscious, interaction” is blocking the provider’s ability to be himself/herself and effectively communicate/interact with patients.1,2

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.2

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.3 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.4-6

When quick solutions are not found, patients are frequently upset, confused, depressed, angry — all of which result in a sense of exhaustion and hopelessness.

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.3

Chronic Pain Mythology

All of these interactions, and expections, 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. 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.2,5,7,8

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.

Last updated on: December 27, 2011
First published on: March 1, 2004