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.

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

4. Physicians

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’

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

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: