Angela Song dissertation by ICSW

Institute for Clinical Social Work

The Impact of Attachment Patterns in Chronic Pain Treatment

A Dissertation Submitted to the Faculty of the Institute for Clinical Social Work in Partial Fulfillment for the Degree of Doctor of Philosophy

By ANGELA N. SONG

Chicago, Illinois February, 2017

Abstract

This study explores the treatment experiences of chronic pain patients and physicians practicing pain medicine. Using a mixed-methods design, ten patients and ten physicians participated in a semi-structured qualitative interview designed to gather information regarding their experiences as a patient in chronic pain treatment and a physician providing chronic pain treatment. Participants also completed the Experience in Close Relationships-Relationship Structures (ECR-RS) to assess their existing attachment patterns. The interview narratives were analyzed using a content analysis approach. Themes found include: variability of chronic pain, resiliency, impact, communication styles, the choice to practice pain medicine, patient perception of physician attitudes; physical, environmental, and psychological realms of chronic pain; components of treatment; relational models of chronic pain; and impact of attachment on dyads. The idea of perpetuating the relationship and the impact of attachment patterns on this task is present throughout the experiences. A possible approach for understanding these experiences using concepts from relational theory and attachment theory is proposed, suggesting that attachment patterns to early caregivers influence how patients relate to their pain physicians. Narrative data complements the ECR-RS categorizations. This studyâ&#x20AC;&#x2122;s potential impact on medical practice and social work practice is discussed and future research ideas and/or applications are proposed. iii

To Annabel, who made every step worthwhile.

One must listen to them carefully to understand that while pain is universal, it is also utterly private. We cannot know whether our pain is like anybody elseâ&#x20AC;&#x2122;s pain until we talk about it. -Viet Thanh Nguyen, The Sympathizer

Acknowledgments

I would like to acknowledge the guidance and influence of my dissertation committee: Barbara Berger, PhD, Lynne Tylke, PhD, Denise Duval, PhD, Carol Ganzer, PhD, and Michael Hoffman, MD. Mike Matrasko was vital in recognizing the need for this research, and recruiting patient participants.. Robert Fong, MD, PhD was invaluable in coordinating with the physician participants, and also in generously subsidizing the project. I thank Sandra MacMahon for her diligent editorial support. Cissy Huang, JD and Bernadette Berardi-Coletta, PhD were instrumental to bridging the medical field with the clinical social work field. I would also like to thank the faculty at the University of Chicago Hospitals, Department of Anesthesiology and Critical Care, for their support and interest in the project. ANS

Table of Contents

Page Abstract……………………………………………………………………….………...ii Acknowledgements….………………………………………………………..….…….vi List of Tables………………..………………………………………….……………...xii List of Figures………………………………………………………………………....xiii Chapter I. Introduction………………………………….………………………………………1 Overview of the Problem Formulation of the Problem

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Table of Contents—Continued

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II. Literature Review………………...…………………………………………………8 Introduction The Chronic Pain Patient-Physician Dyad Relational Theory and the Chronic Pain Physician-Patient Dyad Relational Models of Chronic Pain Impact of Attachment on Dyads Theoretical and Conceptual Framework of the Study Research Questions Theoretical and Operational Definitions of Major Concepts

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Table of Contents—Continued

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III. Methodology………………………………………………………………………41 Research Strategy Study Design Research Questions Sample Selection Data Collection and Instrumentation Qualitative Analysis and Conclusion Formulation Quantitative Analysis Statement of Assumptions Statement on Protecting Human Rights

Table of Contents—Continued

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IV. Results……………………………………….……………………………………57 Participant Demographics Experience of Close Relationships-Relationship Structures (ECR-RS) Chronic Pain Patient-Physician Dyads Relational Theory and Chronic Pain Patient-Physician Dyad Relational Models of Chronic Pain Impact of Attachment on Dyads Field Notes

Table of Contents—Continued

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V. Discussion, Implications, and Conclusions………...……………………………123 The Chronic Pain Patient-Physician Dyad Relational Theory and Chronic Pain Patient-Physician Dyad Relational Models of Chronic Pain Impact of Attachment on the Dyad Schematic Limitations Implications and Conclusion Appendices

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A. CONSENT FORM…………………………………….………….………………143 B. ECR-RS…………………………………….. …………………..…….………......146 C. DEMOGRAPHIC DATA FORMS………………………….....……….………..152 D. INTERVIEW PROMPTS………………………………..………….…………….155 References…………………………………………………………..……...…………..158

List of Tables

Table

Page 1. Participant Demographics………………………………..…………………..58 2. ECR-RS Patients………………………………..…………………………....60 3. ECR-RS Physicians………………………..………………...……………....61 4. Relational Theory and Patient Attachment………………………………....128

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List of Figures

Figure

Page 1. Patient Attachment Pattern Towards Maternal Figure……………….………62 2. Patient Attachment Pattern Towards Paternal Figure………………….…….62 3. Patient Attachment Pattern Towards Partner…………………………..…….63 4. Patient Attachment Pattern Towards Best Friend……..……………………..63 5. General Patient Attachment Pattern……………………...…………………..64 6. Physician Attachment Pattern Towards Maternal Figure…...……………….65 7. Physician Attachment Pattern Towards Paternal Figure……...……………..65 8. Physician Attachment Pattern Towards Partner………………..……………66 9. Physician Attachment Pattern Towards Best Friend……………..……….…66 10. General Physician Attachment Pattern……………………………...…….…67 11. Treatment Schematic…………………...………………………………..…135

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Chapter I

Introduction Overview of the Problem Chronic pain. Chronic pain is a diagnosis that evokes the same as would a dead end, for both physicians and patients alike. A category where the leftover, mysterious, confusing, unresolvable symptoms find themselves lumped together. Most medical specialists send their patients down the chronic pain route as they throw their hands up in defeat. Patients sense this, and often believe that physicians diagnose someone with chronic pain when they cannot “figure it out”. They resist it, and insist on other diagnoses. Perhaps it’s rheumatoid arthritis, a chemical imbalance, anything else, they plead. This commonly held perception sets an unfortunate tone for this area of medicine. It also makes it understandable why there is less research, and less advocacy. People are afraid to examine chronic pain. At the same time, there is no avoiding chronic pain. Chronic pain affects one hundred million Americans. It is broadly described, having no specific etiology and no target organ. It’s only two defining parameters are that the pain has existed for more than six months, and that the pain is resistant to curative treatment. The medical specialty that is officially dedicated to chronic pain is pain medicine. Pain specialists are physicians

who have completed a residency in anesthesiology, followed by a fellowship in pain medicine. In the management of chronic pain, the patient experiences distress and seeks help from their physician. Some patients respond well to treatment and their pain is effectively managed, while others encounter stumbling blocks that challenge the work of the physician, prolong the symptoms for the patient, and drive up cost of care. Treating chronic pain requires communication between the physician and the patient. The quality of the communication plays an integral role in how treatment progresses. One way to think about communication in the physician-patient dyad is to view it as a relationship where both parties have the potential to meet a need of the other. On the surface, pain physicians provide the patients with a treatment plan. Patients provide the physicians with financial compensation. However, there is much more to this transaction, as the challenges suggest. There is an actual relationship. The physician validates the patientâ&#x20AC;&#x2122;s concerns, while the patient validates the physicianâ&#x20AC;&#x2122;s sense of purpose. The needs are addressed through different forms. For example, the frequency and duration of appointments can vary according to need. The content of verbal interaction can be limited to the symptoms of chronic pain, or it can delve into other matters. The experience of chronic pain is personal and intimate, not to mention constant and indefinite for chronic pain patients. The physician-patient relationship can resemble the dyadic relationship between a primary caregiver and an individual. The dependency of the pain patient on their physicianâ&#x20AC;&#x2122;s care can resemble the earlier dependency of a child to a parent, and can therefore evoke the attachment style that was established with their earlier caregivers.

One’s attachment style has been shown to correlate to how one relays their needs to another being. Bowlby, who pioneered attachment theory, defined it as Any form of behavior that results in a person attaining or maintaining proximity to some other clearly identified individual who is conceived as better able to cope with the world. It is most obvious whenever the person is frightened, fatigued, or sick, and is assuaged by comforting and care-giving. (Bowlby, 1988, p. 27) This definition demonstrates how the patient-physician relationship can evoke attachment behavior. When the patient communicates their need to the physician, the physician is impacted by that patient in a particular way. The physician may perceive the patient as suffering or as complaining, as dismissing or as demanding. The physician’s response to the patient’s communication will reflect the physician’s impression, and will also impact the patient. The patient can feel heard and respected, or demeaned and infantilized. Bowlby defined the primary biological function of attachment behavior as “the protection of the individual in the face of threat, not just in childhood, but throughout the entire life cycle” (Ainsworth & Bowlby, 1991).

The patient can find

himself in a helpless state associated with childhood, and therefore view the physician as an omniscient person with power. Attachment theory proposes that interpersonal experiences, sets of behaviors and responses from birth onward, create patterns that evolve into internal working models (IWMs) (Meredith, Strong, & Feeney, 2006). These IWMs become a person’s expectations of the self and others, predicting behavior, thoughts, and feelings (Meredith, Strong, & Feeney, 2006). Attachment behaviors are the internal working model that is

summoned in the face of threat (Mikhail & Henderson, 1994). The experience of pain can be understood as a threat to the self, and can thus conjure pain attachment behavior. For example, insecurely attached patients report less trust in and satisfaction with their physicians, and they have more general distress than securely attached patients (Holwerda, et al., 2013). Another study found that insecurely attached patients have a greater number of physical symptoms compared with secure patients, preoccupied patients have highest costs in care, while fearful patients have the lowest costs (Ciechanowski, Walker, Katon, & Russo, 2002). It may be possible that attachment styles are leading to inefficient use of healthcare. While most of the studies focus only on the patientâ&#x20AC;&#x2122;s attachment and communication style, few explore the dynamic that exists in the interpersonal relationship between the patient and the physician. The impact of the physicianâ&#x20AC;&#x2122;s attachment style is overlooked. In this study, the physicianâ&#x20AC;&#x2122;s attachment style is also taken into consideration. How can this information on attachment be useful to the pain clinic? Understanding the interaction of attachment styles can lead to more effective communication, which can impact the relationship. This is the core idea of the study. Understanding the relational dynamics of the relationship can help overcome barriers so that the patient can successfully adhere to the treatment that the physician recommends for them. Ultimately, finding the ideal relational style between the physician and patient can play a role in delivering positive treatment progress for the dyad.

Formulation of the Problem The purpose of this study was to capture the individual experiences of chronic pain patients and chronic pain physicians that volunteered to be part of the project. The physician-patient dyad is a complex relationship where each person affects the other in significant ways. The physician is a caregiver, a provider that uses their training to help the patient live with their chronic pain symptoms. In chronic pain, there is no cure. Physicians that practice chronic pain management take on the role of the helper, in a field where they are typically heralded more as healers. Thus, they may understand the pathophysiology of the pain symptoms, but they are not able to eradicate the symptoms. The work of the relationship includes not only diagnosing the patient initially, but tracking the patient’s prognosis, being aware of any changes of the symptoms, and responding with an appropriate treatment regimen. Oftentimes, chronic pain symptoms are pervasive and frequent enough that they affect aspects of the quality of the patient’s daily living. Therefore, the work of the pain physician affects the patient’s quality of life on a daily basis. While it may be more readily apparent that patient’s needs are being met by the physician, physicians also get their needs met by the patients. On one level, patients affect the pain physician by impacting the physician’s professional success. Research suggests that patient satisfaction is correlated with time, listening and thoroughness during a patient-physician encounter (Trentman, et al., 2013). Patient satisfaction is important because it is found to be associated with indicators of success including outcome, reduction in pain levels, decreased medical-legal risk, increased reimbursement, and increased referrals (Trentman, et al., 2013) (Hirsh, Atchison, & Berger, 2005).

Considering the physician’s needs in chronic pain care is an area that may be neglected, but has the potential to exacerbate difficulties in treating pain (Frantsve & Kerns, 2007) (Diesfeld, 2008). Studying the pain physician’s attachment styles helped identify some of the physician’s psychological needs so that they too could be considered in determining the most effective mode of communication within the dyad. These findings suggested how the patient’s experiences of their physician influenced the pathways that impacted the physician. The concept that encompasses the impact of physician and patient on one another is relationship. The medical field acknowledges that the physician-patient relationship is key to good patient care and positive health outcomes (Brown, Stewart, & Ryan, 2003). A strong therapeutic doctor-patient alliance is helpful in the management of chronic pain (Lincoln, Pellico, Kerns, & Anderson, 2013). The few studies that have been found in exploring the doctor-patient relationship in chronic pain identify this interaction as a target in improving chronic pain management. The components that are examined are relational tasks, such as investment in the relational matrix, perpetuating the relationship, and regulating the relational field (Mitchell, 1989). For example, the processes of explaining and understanding convey strengths or weaknesses within the relationship (Trentman, et al., 2013). Some physicians see conversation as an opportunity, as the best pain assessment tool available, and that the discussion itself between the patient and physician is the therapeutic intervention (Matthias, et al., 2010). While these ideas make sense in theory, they are not routinely found in practice. Communication is not always as effective, and it is common to find dynamics that disrupt, rather than align. For example, some physicians find their patients to be “manipulative,” “dishonest,” “abusive,”

“explosive,” “angry,” and “aggressive” (Lincoln, Pellico, Kerns, & Anderson, 2013). This kind of disposition prevents the development of a relationship that is needed for effective management of chronic pain. This study created a space to find some ways each side contributed to the relationship. In summary, the goal of this study was to obtain a multidimensional understanding of the participants’ experiences using relational theory as the context for understanding attachment. The attachment style of each participant, combined with the biopsychosocial elements found through their narrative interview, helped reveal how each participant related to their counterpart. The idea was that these methods helped construct a comprehensive understanding of each participant’s experience with the chronic pain treatment relationship. While there were several significant implications for future work, the objective of this particular study was to investigate and identify elements that impacted the experiences and treatment processes of the participants.

Chapter II

Literature Review The following literature review is divided into four major parts: 1. Literature in the area of the chronic pain patient-physician dyad 2. Studies related to relational theory and the chronic pain physician-patient dyad 3. Literature in the area of relational models of chronic pain 4. Literature in the area of attachment theory and dyads

The Chronic Pain Patient-Physician Dyad Chronic pain is described in many different ways. It can last as short as six months, or as long as a lifetime. The pain can be mild or excruciating, episodic or continuous, merely inconvenient or completely incapacitating. These descriptions can also change within one patient, varying in intensity or frequency. The relationship between chronic pain patients and the chronic pain physician is one that must withstand this ever-changing landscape. It also needs to be resilient, creative, and unique to each pair. It requires commitment and investment from both the patient and the physician.

When it comes to assessing the success of chronic pain treatment, the relationship dynamics must be taken into account. However, recent searches of the literature showed very few studies that examined the relationship between chronic pain patients and their pain specialist counterparts (Trentman, et al., 2013). The word “relationship” was broad, and while this specific term was not particularly used, other terms were used to indicate the characteristics of the quality of the relationship, such as “communication”, or “attributes”. In addition, the components of relationship were studied under other definitions, including “patient satisfaction” and “physician attitudes”. Also important to note in thinking about the scant literature was the fact that more than half of all Chronic Non-Cancer Pain (CNCP) cases were managed by primary care physicians rather than pain specialists (Lincoln, Pellico, Kerns, & Anderson, 2013). Studies that examined the interaction between primary care physicians and chronic pain patients actually pinpointed the dynamic between patients, primary care physicians, and pain specialists as an area to be explored, due to the fact that it had been found to be a challenging area (Lincoln, Pellico, Kems, & Anderson, 2013). Primary care physicians felt that requests for consults with the pain specialists were often rejected, ignored, or dismissed (Lincoln, Pellico, Kerns, & Anderson, 2013).

Pain specialists also described

their own struggle with managing chronic pain patients that had been inappropriately treated by primary care physicians whose training may not have been as extensive as theirs (Lincoln, et al., 2013). The physician-patient dyad is a complex relationship where both parties have an impact on each other. Externally, the physician is a caregiver whose care affects the quality of the patient’s physical well-being, while the patient affects the physician’s

professional success. Internally, the two impact each other mentally and emotionally, in areas such as self-confidence, trust, and sense of connectedness. The internal impact also contributes to the external level. The literature review found that high patient satisfaction was associated with improved outcome, which led to reduced medical-legal risk, reimbursement, as well as possible referral to other patients (Trentman, et al., 2013). It was believed that the patientâ&#x20AC;&#x2122;s satisfaction relied on the quality of the physician-patient interaction. Quality was associated with time spent with the patient, listening and thoroughness (Trentman, et al., 2013). Medically, chronic pain treatment satisfaction was found to incorporate more than a reduction in pain level (Hirsh, Atchison, & Berger, 2005). In clinical social work, it is understood that one person alone does not determine the entirety of relational dynamics. Physician satisfaction is also pertinent to the treatment dyad. However, studies considering the experience of the physician in chronic pain care were far fewer. The problem was that the few existing ones suggested that when not attended to, the unconsidered doctorâ&#x20AC;&#x2122;s frustration had the potential to exacerbate difficulties in treating pain patients. (Frantsve & Kerns, 2007)(Diesfeld, 2008). These findings indicated the need to start examining the interplay between both parts of this particular relationship. Expanding the search under criteria such as these led to a small number of studies that were more recent. This indicated a growing interest in the area. While the physician-patient dyad specific to chronic pain had not been reported in large numbers, the field of medicine did consider the general relationship between doctor and patient to have an influence on wellness and treatment. The physician-patient relationship had long

been recognized as fundamental to good patient care and positive health outcomes (Brown, Stewart, & Ryan, 2003). While there was relatively little known about specific factors that providers found to be helpful in the management of chronic pain, the two areas that were consistently found to be helpful were the use of opioids and a strong therapeutic doctor-patient alliance (Lincoln, Pellico, Kerns, & Anderson, 2013). These few studies found that exploring the doctor-patient relationship enabled the identification of this interaction as a target in improving chronic pain management. Specifically, they found that the patient’s perceived outcome of the clinic visit was correlated with the patient’s self-reported sense of health and satisfaction with their experience (Trentman, et al., 2013). The findings suggested that there were tangible goals that could be achieved by designing specific tasks. These included explaining the patient’s conditions and treatment, providing instructions, and taking the time to understand the patient’s values (Trentman, et al., 2013). Some physicians saw conversation as the best pain assessment tool available, and they believed that the discussion itself between the patient and physician was the therapeutic intervention (Matthias, et al., 2010). On the surface, these aspects appeared within reach, yet they were not routinely encountered. The strong therapeutic doctor-patient alliance seemed to be elusive, as antagonistic patient-provider interactions were found to be recurring themes in chronic pain. These interactions were barriers to the development of mutually satisfying relationships. In addition, other interpersonal dynamics in doctor-patient dyads needed to be studied in order to facilitate the delivery of positive outcomes. Exploring the quality of the dyad meant thinking about the communication between the doctor and the patient, including examination of

how each person communicated in general, and what they found to be helpful or not helpful in their specific encounters. A key component in patient satisfaction and communication was the role of empathy. Some studies showed that empathy was important not only in all physicianpatient relationships, but particularly in the management of pain treatment (Tait, 2008). Some clinical medicine groups started to explore this idea, and looked to the therapeutic alliance that was critical in psychotherapy, as a model of what empathy in the relationship could provide. This study drew on relational theory to explore the possible impact between the relationship and the management of pain treatment.

Relational Theory and the Chronic Pain Physician-Patient Dyad There was little to be found in relational theory that examined the chronic pain physician-patient dyad specifically, but there were several areas that were highly relevant. For example, how relational theorists understand chronic pain, had been discussed in context of analysts treating patients who suffer from a chronic illness (Perlman, 1996). Their work acknowledged several ideas that supported further exploration of this physician-patient dyad. One thought was that pain was an experience with physical, environmental, and psychological causes (Perlman, 1996). Therefore, in addition to the physical, each of these areas needed to be considered in the management of pain. Psychoanalytic conceptualizations helped access the environmental and psychological causes to help treat chronic pain (Perlman, 1996)(Taylor, 2008). What appeared to be effective was increasing the patientâ&#x20AC;&#x2122;s understanding of their chronic pain,

which was used to bring forth meaningful change (Perlman, 1996)(Shapiro, 2003)(Taylor, 2008). For example, a patient who once viewed their chronic pain as a personal defect, was able to see it as an opportunity to develop a strength. The meaningful change came from transforming what was represented by chronic pain. Merging the areas of biology and psychology turned out to be an obstacle to further exploration of the chronic pain physician-patient dyad. There were experts in both areas and a vast amount of literature explaining the way in which each independently influenced the issue of chronic pain management. However, there were very few attempts to study a combination of the two realms. The goal of this study was not to suggest that psychoanalysis alone was the solution for chronic pain, or that chronic pain was managed solely with the use of physical interventions. Rather, the goal was to investigate the idea that an integrative approach may offer the best hopes for managing chronic pain (Perlman, 1996)(Shapiro, 2003)(Taylor, 2008).

In examining clinical

vignettes of the psychoanalyses of chronic pain patients, much of what unlocked the struggle, and paved the way for therapeutic gain, were the dynamics of the relationship dyad. Perlman described the value of understanding how the patient stored generalized stress and tension in the body, and how the analytic process helped the patient process the experience of what was stored in memory (1996). The question was not about whether the chronic pain physician was able to process the patientâ&#x20AC;&#x2122;s experience on an analytic level, but whether the finding of such understanding was encouraged. In other words, did the communication style within the dyad promote finding meaning to the patientâ&#x20AC;&#x2122;s experience? Or was the patientâ&#x20AC;&#x2122;s experience seemingly neglected, dismissed, or not highly prioritized? This required venturing into the medical realm, outside of the

traditional psychotherapeutic setting. For example, one study examined the first encounter with chronic pain patients in an outpatient pain clinic (Borghetti-Hiscock, 2007). In this particular setting, there was a designated “pain psychotherapist” who offered optional appointments to patients who were identified as showing no improvement from traditional interventions. It was suggested that when the traditional interventions were not improving pain symptoms, there was an emotional element in their pain, which “interfere[d] with their recovery or even their capacity to communicate with their doctor” (Borghetti-Hiscock, 2007). This statement alone helped identify complexities and mythologies within the chronic pain physician-patient dyad. One belief was that the more difficult chronic pain cases involved the emotional realm. Another belief was that the emotional realm fell solely on the shoulders of the patient, that it was the patient’s emotional problem, and that the patient should address it so that the doctor could fix the pain. Borghetti-Hiscock’s study actually addressed these weighted beliefs, and helped break down the one-sidedness by discussing the role of the pain psychotherapist. The focus shifted from implicating the patient’s emotional health as the cause of a “difficult case” and instead examined “technical difficulties and use of counter-transference in the attempt to understand these patients’ communications” (Borghetti-Hiscock, 2007). In their study, the pain psychotherapist drew on fundamental therapeutic techniques, such as the analyst’s need to just listen and wait, respecting both the language of the body and the language of the mind. Employing such techniques resulted in the patients moving toward a willingness to examine their internal worlds, which Borghetti-Hiscock believed to be key in thinking about their emotional pain. The ultimate result was that there was a general improvement in their capacity to allow others

to look into their problems and also to express the problems more clearly (BorghettiHiscock, 2007). This study was not about how psychoanalysis was able to cure the chronic pain patient of their pain, but how management of their pain was improved by helping create a more collaborative dyad between the caregiver and the patient. This idea was not limited to the challenging cases of chronic pain, but was helpful in a more general sense in establishing the long term, chronic pain physician-patient relationship. The physician-patient relationship embodies many shared components of the psychoanalytic relationship. McShea’s work offered a framework that could help better understand the similarities. His research drew from congenital chronic pain, specifically sickle cell disease, which required the establishment of a relationship from the earliest developmental years. McShea suggested that in the early phases of the chronic illness, internal pain was attributed to external origins, and the effects of this relationship were similar to that of physical abuse (McShea, 2007). The patient was helpless, and failure to contain the patient’s pain from early on developed deeply ingrained defense mechanisms including projective identification and persecutory anxieties (McShea, 2007). Understanding the experience of pain in such a manner supported the need for methods such as healing trauma and building trust (McShea, 2007). Every component of the dyad was a rich resource of information in understanding the experience, such as hearing the patient’s pain complaint as a privileged means of relationship (Guittard-Maury, 1996)(Shapiro, 2003). Director’s (2002) understanding of chronic drug and alcohol use was also used to think about chronic pain. Director believed that:

Chronic substance use is seen as being driven by conflicting and unresolved relational dynamics that derive from the early organizing relationships in a person’s life…the terms of this conflict find concrete expression in characteristic acts of drug use that serve to perpetuate it through the combined effects of reinforcement and disguise (2002) The pain complaint could be understood as a concrete expression, which would otherwise leave the patient without a means to express their experience. Eagle’s case study demonstrated how enactments in the dyadic relationship could be used to also access the patient’s experience of their pain (Eagle, 1993). While Eagle’s case study depicted the enactments in the analytic relationship, it provided a framework for examining enactments that might occur in the chronic pain physician-patient dyad, such as noncompliance. The lens of relational theory helped understand the dynamics of the dyad, and inform of communications that may be more effective and collaborative. Some of the psychoanalytic literature depicted the physician’s need for improved collaboration as well. Improving communication could not happen by understanding solely the patient’s experience. Kraemer’s work studied the caregiver’s deep desire to be recognized and understood by the patient (Kraemer, 2006). This study focused on the dynamics between the physician and parents of patients in the NICU, and its findings further supported the medical field’s understanding of the physician-patient dyad. These articles were not written by a relational psychoanalyst, but were established under the heading of communication by the medical field.

Relational Models of Chronic Pain While psychotherapy addresses psychic pain, its theories could offer a framework for understanding physical pain, such as chronic pain. For example, pain may be an integral part of the patient’s sense of self, which can impact how the patient addresses their pain. McDougall demonstrated why pain may be experienced as such, and what may also be done about it. McDougall offered the “psychosomatic personality”(1989), which could be generally summarized as operatory thinking that described a largely pragmatic way of relating that was devoid of feeling (1989). One’s own feelings, as well as the feelings of others, were not acknowledged. People who had experiences that ought to be rich with intense feelings (i.e. trauma) were instead described as being calm, perhaps emotionless. McDougall believed that one consequence of habitually eliminating the experience of overwhelming emotion was the increase of psychosomatic vulnerability (1989). Her hypothesis embraced the structure of the mind-body connection in which both sides impacted the other in a synergistic manner, flowing from one side to the other at the same time. It was bidirectional. For example, physical symptoms were understood as protection against “truly archaic libidinal and narcissistic longings” (McDougall, 1989) that were felt to be life-endangering. When such danger was sensed, a “primitive psychic message of warning” is sent to the body, bypassing the use of language. This is an immediate process, which bypassed the function of thinking about the danger. The physical action was understood as psychosomatic dysfunctioning, occurring in symptoms such as emptying the body of its contents or holding one’s breath. Again, these responses were autonomic in physical process, requiring no thought or processing. In addition, the body, like the mind, was subject to repetition compulsion,

which drove immediate transmission without the opportunity for emotion to be recognized in a symbolic way. Also interesting to note was that the psychic phenomenon of survival was reinforced, despite the fact that emotions were bypassed. Without addressing emotions, these autonomic processes delivered a sense of protection, which helped alleviate fears. The physical symptoms were understood as reassuring proof that one’s body was alive. McDougall also pointed out that while the struggle with psychosomatic symptoms could feel as though they could culminate in death, (and in some instances, they could actually lead to death), they also represented an attempt to survive. This schematic helped explain the underdevelopment of emotional presence in some patients who suffered from somatic illness. As McDougall stated, these patients allowed their body to “do all the feeling and thinking” (McDougall, 1989). The outcome was as drastic as eradicating all strong feelings. An experience that caused emotional flooding would not be recognized and therefore was not contemplated. This was reflected in relationships with others, which were described as notably unemotional or utilitarian, denying the importance of depending on another person (McDougall, 1989). How interesting then, that these very symptoms brought them to the pain clinic, forcing them to actually depend on another. This was just one schematic, and it existed on a continuum. McDougall explained that for some patients, it was not the entirety of emotion that was not being processed, but perhaps the excess of the affective experience. This excess was variable, which again brought into consideration the role of one’s attachment style. One’s attachment style could impact the threshold for affect. In addition, capacity can differ from threshold.

For example, alexithymia was defined as the inability to distinguish one affect from another. In this case, the question was not how much affect was tolerated, but whether affect registered at all. Those with alexithymia appeared to be unaware of important emotional upsurges. This too could result in dispersing the intensity of emotion through engaging in action, of evacuating the unbearable affective arousal, and also increasing vulnerability to psychosomatic symptoms (McDougall, 1989). McDougallâ&#x20AC;&#x2122;s view of emotion provided a way of understanding the mind-body connection. McDougall believed that emotion was essentially psychosomatic. Ejecting the psychological part of an emotion allowed the physiological part to express itself as in infancy, which could lead to a resomatization of affect. Early emotions were thus experienced physically. When adult patients struggled with emotional regulation on a psychic level, they would experience the emotion through their bodily senses. The signal from the psyche was reduced to an action message devoid of words. Individuals who handled emotion in this way were likely victims for psychosomatic explosions when events such as accidents, births, deaths, divorces, and abandonments occurred. This understanding of the mind-body connection provided some rationale for exploring the patientâ&#x20AC;&#x2122;s experience of their chronic pain during the qualitative interview in the study. For example, what did the patient remember about their life situation around the onset of their chronic pain? What events did they remember? What emotions did they remember? McDougall also discussed the impact of processing emotion without the psychological component. She stated that without its warning signals, certain individuals ran the risk of not knowing that they were feeling threatened psychologically. This

sometimes manifested in addiction behaviors, such as the overpowering need for medication, food, tobacco, alcohol, or opiates. As a counter to feeling overwhelmed, they used substances to regulate when they were unable to self-regulate or co-regulate. The addiction served a soothing function, of objects to be attacked and mastered. The abuse of pain relieving substances was a concern in the chronic pain population. Abuses and compulsions were behaviors that could serve the same purpose of calming the self that was unknowingly feeling threatened. Abuses and compulsions were observed in the chronic pain physician-patient dyad. These areas were then combined to suggest an addiction to relationships, and the possibility of feeling empty, misunderstood, or out of touch with others when that addiction was not satisfied. Those who chose to satisfy this type of addiction unfortunately were not able to fulfill this function for very long, which left the patient enraged. McDougall believed these figures were “unconsciously treated like the ‘breast mother’ of infancy, who [was] held responsible for all the baby’s pleasure, as well as all its pain” (p. 91, 1989). It was interesting to learn what kind of expectations or fantasies the chronic pain patient had for their physician to fulfill. Communication of the expectations of both the patient and the physician became a key element in understanding the dyad. McDougall stated: Words are most effective containers for channeling the energy linked to instinctual drives, as well as the fantasies to which they have given birth, with regard to the parental objects of infancy. When words do not perform this function (for reasons that remain highly conjectural), the psyche is obliged to give distress signals of a presymbolic kind, thereby circumventing the restraining links of language. There is

then a considerable risk of evoking somatic instead of psychological responses to the experience of wordless anguish. (p. 101. 1989) This quote showed the value of words and the outcome of not having words. There was an importance to knowing whether the dyad had access to words. Examining the language that was used reflected how secure or safe the relationship felt to the patient or the physician. McDougall also stated: This capacity to foreclose certain perceptions, thoughts, fantasies, or other psychological events is operative in the adultâ&#x20AC;&#x2122;s regression to psychosomatic rather than psychological responses to conflict and psychic pain.

There is a dissociation

between word-presentations and thing-presentations, so that the bodily signals of anxiety become equivalent to a thing-presentation, severed from the word-presentation that would give meaning to the experience. (p. 102, 1989) This idea raised the possibility that the symptoms could be the actual mode of communication that was being used in the dyad, particularly when words were not accessible. This was true in the study. Understanding the meaning of the management of those very same symptoms between the doctor and patient was important. Relational theory was used to understand chronic pain and the process by which it was addressed and treated within the physician-patient dyad. For example, Mitchell summarized the classical view of the entire spectrum of psychopathology as being the "tendency of people to do the same painful things, feel the same unpleasant feelings...over and over and over" (Mitchell, 1988). In chronic pain, patients also experienced the same painful

things over and over again. They may or may not have felt the same unpleasant things repeatedly, but their physician may not have been aware of this aspect. If painful memories were stored implicitly, they may not have accessed them consciously, symbolically, or explicitly. This was not something the physician could always understand. The patientâ&#x20AC;&#x2122;s awareness and ability to discuss this experience with their physician affected the relationship between them. Fairbairn's theory surmised that the basic human need was not for pleasure or need gratification, but for an intense relationship with another person. The relationship with their chronic pain physician could have been a vehicle for interaction with others. When pain was the only familiar experience to the patient, it was what they sought. This also affected the physician-patient dyad in chronic pain management. Mitchell suggested that it was the contact, not the pleasure, which was primary. Painful feelings, selfdestructive relationships, self-sabotaging situations were recreated throughout life as vehicles for the perpetuation of early ties to significant others (Mitchell, 1988). Chronic pain may have provided a psychosomatic vehicle for sustaining familiar experience of early relationships. Fairbairn believed that these vehicles helped preserve a powerful bond, and that these efforts for preservation were rooted deep within. Mitchell explained that in Fairbairn's theory, the core of the repressed was not trauma, but a relationship; a part of the self in close identification with a representation of the actual caretakers, which could not be contained in awareness and in continuity with other experiences of the self (Mitchell, 1988). This helped understand some of the patterns that were observed in the physician-patient dyad, especially those that were puzzling at first. For example, it helped explain avoidant behaviors from a patient, or dismissive ways of working from a

pain physician. The chronic pain dyad was a unique setting that offered both the physician and the patient the opportunity to preserve and repeat these primary experiences. The chronic aspect indicated the need for a long-term significant relationship. For the patient, chronic pain was the component that necessitated the connection. For the physician, chronic pain provided the motivation and rationale for the relationship, because these relationships constituted part of their career and generated a livelihood. These possibilities also represented the design of needs that Sullivan suggested in his theory. Sullivan recognized the role of objects, stating that humans were drawn into relatedness by virtue of the form and nature of their various needs (Mitchell, 1988). Mitchell's summary of the relational model provided a way of interpreting the dynamics that were observed in a physician-patient dyad. He wrote: Relational model rests on the premise that the repetitive patterns within human experience are derived from a pervasive tendency to preserve the continuity, connections, familiarity of oneâ&#x20AC;&#x2122;s personal, interactional world.

There is a powerful

need to preserve an abiding sense of oneself as associated with, positioned in terms of, related to, a matrix of other people, in terms of actual transactions as well as internal presences. (Mitchell, 1988) Perhaps a sense of oneself was preserved in the physician-patient dyad which affected chronic pain management. Mitchell identified a basic relational configuration of three dimensions- the self, the other, and the space between the two (Mitchell, 1988). These three dimensions were built on many components, including the attachment styles

of the self and the other. These attachment styles may have influenced the success or failure of this connection, and influenced the ongoing dynamics within the relationship of doctor and patient. The patient-physician relationship triggered old secondary attachment patterns for both in a non-conscious manner. This basic configuration exists in any relationship, but Mitchell's work also encouraged consideration of the impact of chronic pain. For example, Mitchell stated that in psychoanalysis, analytic dyads with repetitive disturbances in interpersonal relations were especially drawn to specific negative types of relations (1988). In particular, Mitchell stated that "this compulsive repetition of painful early experience seem[ed] to reflect a detachment from some forms of relationship, and also an attachment to certain others" (1988). Interesting to note, the draw was â&#x20AC;ŚNot satisfying features of their relationship, but precisely the features that are missing. It is the deprivation, the pain, the depression, which serve as vehicles for attachment. The analysand does not simply miss or exclude from consciousness signals which would lead to nurturance and attachment; he looks for different cues, which draw him into attachments not based on caring and support but on pain and misery. (Mitchell, 1988) This was thought to be residual from the early experience. It may have been the only way to connect and it was the price of having a connection and not being adrift in the ambivalently attached patient. In this model, pain unlocked intriguing ways of understanding the dynamics of the relationship between the chronic pain patient and their

physician. Examples of such patterns were found in the patients and physicians who participated in this study. This brief overview of how pain could reinforce inter-relational patterns, acknowledged the power of pain. It was valuable to then also consider how pain itself was understood in the relational model, that is- what did pain mean to the patient, and what did pain mean to the physician who managed their patient’s pain? Again, while the literature in psychoanalytic theory did not address chronic pain specifically, it provided some possible frameworks to understand how people made meaning of pain. Pain was understood as a foundation of one’s sense of being. Mitchell wrote: The analysand’s subjective world may be painful, but it is his; and in some deep sense, he wants it just this way (even though he also may not). His conscious, willful commitments and choices support and embellish unconscious commitments and choices- the larger, more complex design which shapes his experience. It is an increased awareness of himself as both the design and the designer that makes possible a richer experience of living. (1988) This way of understanding pain showed the conflict in eradicating pain. It was one way of depriving one of their sense of self and of life. To experience pain was to have a self-experience. If this were the meaning of pain to a patient, managing their pain would look very different from that of a physician whose goal was to eliminate their pain. This possibility stressed the importance of effective communication between the patient and the physician, which was also an arena that was impacted by each person’s attachment style.

Impact of Attachment on Dyads The review of relevant literature in relational theory showed that there were more studies on the patientâ&#x20AC;&#x2122;s experience, but stressed the importance of the contributions of the caregiver. In the dyadic relationship, the attachment styles of both the patient and caregiver had an impact on the therapeutic dyad. It was then reasonable to believe that attachment styles would also affect the physician-patient dyad. In dyadic work, such as couple therapy, tenets of attachment theory were used to understand the dynamics of the current relationship. While attachment theory concerned early primary relationships, attachment patterns also had an impact on adult relationships. For example, it was believed that the individual developed internal working models that persisted over time, and that the individual grew up with these internal working models as implicit relational knowledge (Lyons-Ruth, 1998). This became the basis that one was accustomed to in a dyadic systems matrix (Feld, 2004). It was possible that behaviors of attachment patterns also surfaced in chronic pain physician-patient relationships. John Bowlby provided a platform to understand attachment behaviors in the context of both psychology and biology. Examination of the relationship between a child and its caregiver showed the necessity of attachment for survival of the child, not only emotionally, but also physically. This skill was likened to the biological processes of feeding and mating. Such innate behavior was understood to be universal- every being had an attachment behavior. The specifics of attachment behavior were varied, and were determined based upon three responses to threat and insecurity of oneâ&#x20AC;&#x2122;s physical survival:

1. Seeking, monitoring, and attempting to maintain proximity to a protective attachment figure 2. Using the attachment figure as a “secure base” 3. Fleeing to an attachment figure as a “safe haven” in situations of danger and moments of alarm (Bowlby, 1969). Mary Ainsworth worked with Bowlby’s theory, most significantly through the Strange Situation study, which established the idea of the caregiver as a “secure base”. The data and analysis from her study culminated in the identification of three distinct attachment patterns. These were: secure attachment, avoidant attachment, and ambivalent attachment (Ainsworth, 1970). Secure attachment reflected equal access to exploration when the child felt safe, and the seeking of solace when the child felt threatened. Avoidant attachment showed more comfort with exploration, due to the impact of experiencing unreliable solace when needed. In this situation, an alternative to a secure attachment to the caregiver was an attachment to inanimate objects instead. Inanimate objects were more reliable, and the self was more reliable or useful as a problem solver, than the “other.” Ambivalent attachment featured a preoccupation with the caregiver such that exploration did not occur with safety, and there was overwhelming distress when the child felt threatened (Ainsworth, 1970). Here, the child’s entire focus was on the caregiver at all costs, forsaking any other needs just for the chance of a connection with the caregiver. The connection with the caregiver became primary. Later, Ainsworth’s student, Mary Main, added a fourth category, which was the disorganized attachment category. This category conveyed an added complexity to the

situation in which the caregiver was simultaneously the source of solace and the source of threat. Such a paradox was understood to produce disorganization in the relationship (Main, 1986). Ainsworth studied the actual communication style between the infant and the caregiver to derive these categories. The infantâ&#x20AC;&#x2122;s expressions and the motherâ&#x20AC;&#x2122;s responses were examined, along with the outcome of the interaction. For example, they observed whether the pair was able to achieve solace together. This provided a framework for studying the patient-physician dyad. It provided a method to understand what their relationship conveyed about what could be achieved together. It examined how each personâ&#x20AC;&#x2122;s attachment style contributed to the relationship. In the Strange Situation Procedure (Ainsworth, 1970), researchers observed the subjects in a series of eight configurations: parent, infant and researcher all together, parent and infant alone, stranger joining the parent and infant, parent leaving the infant and stranger alone, parent returning and stranger leaving, parent leaving (infant is completely left alone), stranger returning, parent returning and stranger leaving. They noticed four behaviors throughout the phases: 1. Separation anxiety 2. The infant's willingness to explore 3. Stranger anxiety 4. Reunion behavior The study resulted in the identification of three main attachment styles (not attachment patterns), which were: secure attachment, anxious-avoidant insecure

attachment, and anxious-resistant insecure attachment (also known as ambivalent attachment). In general, it was believed that the attachment style was activated by the departure and return of the caregiver. Secure attachment was believed to occur when the caregiver was available and able to meet the needs of the child in a responsive and appropriate manner. These characteristics facilitated the childâ&#x20AC;&#x2122;s capacity to explore freely when the caregiver was present, and to engage with strangers. The understanding was that no exploration or play could take place if the security with the parent was not resolved. The child could also express upsetness when the caregiver departed, and could express happiness at reunion (Ainsworth, 1970). Ambivalent insecure attachment was believed to occur when the caregiver was unpredictably responsive in caregiving, which resulted in the child responding in ways that were intended to preemptively take control of the interaction. This evoked behaviors that communicated high distress, ambivalence, and reflections of anger or helplessness (Ainsworth, 1970). Anxious-avoidant insecure attachment was believed to occur when the caregiver was not able to meet the child's needs, and the child believed that their efforts to communicate those needs has were not effective on the caregiver. The child developed responses that masked their level of distress, such as avoiding or ignoring behaviors. They limited their emotion, as well as their exploration (Ainsworth, 1970). Ainsworth felt that a fourth style should be included to account for behaviors that were not covered by the three. Mary Main, who also worked with Ainsworth, identified

the fourth style, which was the disorganized insecure attachment style (Main, 1986). This style reflected a disorganization in the coordination of a response to the caregiver’s departure or return. Rather than displaying a specific behavior, behaviors felt out of step with the phases of the protocol, which was believed to indicate a disruption or flooding of the attachment system. The disruption (i.e. fear, anger) was not just the child’s own, but also contributed by the caregiver. For example, unresolved trauma in the caregiver’s history resulted in a disoriented quality in the relationship with the child, which led to disorganized insecure attachment between the caregiver and the child. Bowlby, Ainsworth, and Main’s works motivated many groups to design instruments to identify these attachment styles. Bartholomew et al. constructed a fourcategory, two-dimensional model of attachment (Bartholomew, Henderson, & Dutton, 1990). Bartholomew’s instrument incorporated one’s perception of an other, and of the self. The positivity of the self-dimension was measured on the x-axis, and the positivity of the other dimension was measured on the y-axis. Positivity of self indicated the degree to which individuals had an internalized sense of their own self-worth (Bartholomew, Henderson, & Dutton, 2007). The positivity of the other dimension reflected expectations of the others’ availability and supportiveness (Bartholomew, Henderson, & Dutton, 2007). The positive other model indicated one’s willingness to seek support from close others (Bartholomew, Henderson, & Dutton, 2007). A negative other model indicated one’s tendency to withdraw and maintain a safe distance within close relationships, particularly when feeling threatened. Brennan, Clark, and Shaver (1998) developed an instrument that was very similar to Bartholomew’s. Brennan’s group measured avoidance behavior on the y-axis, and

anxiety driven behavior on the x-axis. The resulting plot of avoidant and anxious behaviors visually demonstrated the relationship of how one related to an other. This was much like Bartholomew’s use of the other. Fraley, who conducted a meta-analysis of attachment style measuring instruments, found that these two groups were the most strongly correlated with the work of Ainsworth and Main. Fraley developed the Experience in Close RelationshipsRelationship Structures (ECR-RS), as a revised version of Brennan’s Experience in Close Relationship. The ECR-RS was the instrument used in this study. A preoccupied attachment category, which correlated with Ainsworth’s ambivalent attachment style (Brennan, 1998), reflected an overly-dependent style that had intense feelings of unworthiness and an excessive need for other’s approval (Brennan, 1998). Experiences of inconsistent and insensitive caregiving were thought to contribute to preoccupied attachment, in which one had a positive model of others, but a negative model of the self (Bartholomew, Henderson, & Dutton, 2007). Individuals with preoccupied attachment styles had an urgency to get their needs met, which manifested in an intrusive, demanding interpersonal style. Fearful attachment, which correlated with Main’s disorganized insecure attachment style (Brennan, 1998), reflected a more avoidant behavior, despite yearnings for acceptance by others (Bartholomew, Henderson, & Dutton, 2007). Individuals with fearful attachment styles believed that others were uncaring and unavailable, and that they themselves were unlovable. While hypersensitive to social approval, they avoided intimacy to avoid rejection. They managed their fears and anxieties by maintaining a

distance (Bartholomew, Henderson, & Dutton, 2007). This was parallel to the constant push and pull that was often seen in borderline patients that were managing their attachments. Dismissing attachment, which correlated with Ainsworth’s avoidant insecure attachment style (Brennan, 1998), reflected behavior that also featured distance, but with a positive self-model. The distance was a façade that was developed as the child adapted behaviors that covered up the distress that they may have been feeling. Thus, the child’s respirations, blood pressure and endocrine may have been reactive, but their outer appearance worked to hide these signals. The cover up indicated that they had given up on the hope that they could get their needs met by another person, and that they were choosing inanimate objects or their own intellect to try to fulfill those needs instead. Such adaptations were typical of the schizoid patient or the obsessive compulsive patient. The distance actually helped maintain that positive self-image. Dismissing individuals emphasized self-reliance, emotional control, and tended to downplay the importance of intimate relationships (Bartholomew, Henderson, & Dutton, 2007). Meredith also found that dismissing attachment styles were associated with high pain self-efficacy (Meredith, Strong, & Feeney, 2006). Secure attachment reflected interdependency (Solomon, 2009). Security demonstrated the capacity to be more separated and individuated, but also not having to become solely self-sufficient or impenetrable. It manifested in flexibility and resourcefulness in getting needs met. Securely attached individuals were able to “take emotional risks, reach out to and provide support for others, and cope with conflict and stress” (Solomon, 2009).

Bowlby believed that the strength of attachment bonds was unrelated to the quality of the attachment relationship. An interesting finding in the literature was that the most stable relationships were not necessarily limited to secure attachments (Bartholomew, Henderson, & Dutton, 2007). This finding demonstrated that less healthy combinations could maintain relationships. This had varying implications for the physician-patient relationship. There was no formula for establishing a strong, secure treatment relationship. Information about attachment styles required that these relational dynamics be considered in the development of each doctor/patient dyad. In other words, one pain physician would not necessarily work in the same manner with every single patient. How the two worked together best depended on how each of them related to one another. Stability was not necessarily healthy, since a stable relationship could still perpetuate avoidant attachment styles. Thus, a physician and a patient could have a stable, predictable way of interacting, but they would not be addressing the patientâ&#x20AC;&#x2122;s medical needs effectively. Rather, pain would drive the existence of the relationship, and relief reduced the need for it. This example suggested that there were layers of mechanisms that perpetuated the relationship, with both conscious and unconscious reasons for its presence. Pain was the primary factor that allowed the relationship to continue and was a driving force in keeping that relationship stable. This helped explain some of the findings in healthcare utilization. Ciechanowski et al. found that patients with preoccupied attachment styles tended to have the highest primary care utilization and costs, in contrast to patients with fearful attachment styles who had the lowest primary care utilization and costs (2002). In addition to financial costs were the costs of

delayed medical care, which embodied further impact on the treatment relationship and probably the results of treatment. In addition to the relationship between attachment patterns and dyadic dynamics, it was also important to consider the relationship between attachment patterns and the response to pain. In her review, Meredith found that the behaviors and emotions associated with adult attachment patterns influenced the ways in which people in pain responded to medical and therapeutic interventions (Meredith, 2013). For example, those with insecure attachment patterns were frequently less able to cope adaptively with the distress of an unrelenting stressor, such as chronic pain (Meredith, 2013). Not only was the current pain difficult to manage, but the distress could be further magnified by the influence of one’s attachment (Meredith, 2013). Those who had low comfort with closeness tended to have higher levels of disability, and higher levels of pain intensity. This reflected the experience of pain in attachment styles that featured anxiety towards close relationships. Meredith’s review also pointed to the absence of studies incorporating attachment patterns of people without pain, who went on to develop chronic pain. It was interesting to consider the reverse impact, where the experience of pain could also impact one’s general attachment pattern. Meredith discussed the idea that chronic pain caused a shift towards insecurity (Meredith, 2013). The idea was that chronic pain activated behaviors that could alter one’s attachment style, because one’s sense of self was threatened by the pain. Enduring unrelenting pain (in this case, due to the chronic nature of the pain) could cause this gradual shift.

The impact of a relationship on an attachment pattern was yet another relevant idea. Literature on attachment theory in couple therapy suggested that a long term relationship involving one partner with a secure attachment pattern could result in an “earned secure attachment style” in the other (Solomon, 2009). This finding attested to the possibility of general attachment patterns shifting across categories. By generalizing these findings, it became evident that the relationship between the patient and the physician could also cause a shift in attachment styles. Chronic pain embodies many symptoms that remain a mystery to the medical field. Patients with chronic pain may have trauma in their history. Sometimes, the trauma may be directly linked to the chronic pain symptom, whereas other forms of chronic pain may be somatizations of traumatic experience. Lyons-Ruth found that traumatized individuals exhibit avoidant, disorganized, or ambivalent strategies of stress regulation (Lyons-Ruth, 2001). One’s attachment style affected their ability to regulate emotions (Fonagy, 2002; Schore, 2003). The regulation of emotions was a key part in processing trauma, and was regarded as an indicator of whether the experience of the trauma was unresolved. Thus, understanding the patient’s attachment style could help the physician have a different approach to what may have felt like barriers to treatment. The physician’s ability to respond to the patient in an effective way also depended on the physician’s attachment style. Bringing together the attachment styles of both the physician and the patient offered the opportunity to consider the outcome of the various possible combinations. The experience of chronic pain is complex for both the patient and the treating physician. Among many implications, this can be seen as an acknowledgement of the

mind-body connection between physical pain and psychological suffering. The different fields involved accept that chronic pain and psychological disorders were identified as comorbid conditions (Frantsve & Kerns, 2007) (Sullivan, Leigh, & Gaster, 2006) (Turk & Okifuji, 1997). Applying models across the fields helped enrich oneâ&#x20AC;&#x2122;s understanding of the experience of chronic pain. Chronic pain is a type of suffering that is embodied in the physical, environmental, and psychological. There is a need for this multidimensional approach in order to have a better understanding of what it is like for patients to live with chronic pain, and for physicians to treat chronic pain. This study researched an integration of theory and experience that generated a complex psychodynamic understanding of this experience. Current literature showed a need for creating a multifaceted approach to interpreting the meaning of these experiences from both the patient and physicianâ&#x20AC;&#x2122;s perspectives. Bringing together the various elements created a more comprehensive way of understanding what occurred in the treatment relationship. Attachment styles are a fundamental part of each person, and they often determine how a person gets their needs met. Attachment styles are shaped by the biopsychosocial elements that are rooted in the personâ&#x20AC;&#x2122;s early childhood experience. They determine how a person relates to another person. This study explored the attachment styles that were found in chronic pain patients and the physicians who treat chronic pain. The attachment patterns of both came together in an integrated area, which was the treatment relationship. The characteristics of this relationship enhanced or inhibited the experience, and was impacted by both the attachment style and the meaning of chronic pain for each.

Every chronic pain patient had a way of thinking about their pain, of managing their pain, and working with their pain physician. Likewise, every pain physician had a way of thinking about the pain that they were treating, using their medical training to determine a treatment course, and working with their patient. This study investigated the integration of the psychological, medical and environmental contexts. It embodied the experiences of the patient and physician toward the end of understanding the power of the treatment relationship.

Theoretical and Conceptual Framework of the Study The experience of pain is universal. No human goes through life without experiencing pain. How one responds to pain provides information about the personhow they function, what their protective mechanisms are like, and how they utilize their resources. Oneâ&#x20AC;&#x2122;s response to pain reflects how they cope and adapt. Coping and adaptation are part of the foundation of attachment theory. Attachment theory was originally developed to study the reaction to loss and separation (Simpson, 1998). Such events activate attachment processes. Attachment styles determine how a person organizes their experience and handles their distress (Simpson, 1998). Attachment styles are said to be developed during the formative years, and carried on through adult life. This does not imply that attachment styles are rigid. They can be changed through later experiences. A component that allows such fluidity is that attachment styles are dependent on one's view of themselves, and their perception of how others view them (Simpson, 1998). Thus, the dynamics of a relationship become influential in defining one's attachment style. Research areas in attachment theory

include affect regulation, internal working models, social support, conflict resolution, and relationship centered anxiety (Simpson, 1998). All of these areas suggest a relational component. The interaction of attachment styles manifest in different ways of relating: The power of interaction is the primary idea behind relational theory. Relational theory purports that the internal world is shaped by and inevitably embedded within a matrix of relationships with other people, struggling both to maintain our ties to others and to differentiate ourselves from them...the basic unit of study is an interactional field within which the individual arises and struggles to make contact and to articulate himself...mind is composed of relational configurations... (Mitchell, p. 3, 1988)

The chronic pain treatment experience does not exist in isolation. How the patient experiences chronic pain treatment affects how the physician experiences it, and vice versa. There is indeed a matrix of interaction in the treatment relationship, and the impact of this matrix must be considered when attempting to capture as complete of an understanding as possible. It is the intertwining of these areas that provided a complete, intriguing framework for this study. Relational theory and attachment theory were used to guide the study. This study captured the experiences of chronic pain treatment at a level that examined the dynamics of a relationship, and their impact. Chronic pain patients and their physicians work in a long-term partnership, the success of which depends on managing the impact of each on the other. Chronic pain itself activates the attachment system by posing danger and threat to the patient, both physically and psychologically. Chronic pain requires coping and adaptation for a prolonged period of time, and adjustments are usually necessary. Capturing the responses of both the patient and the

physician provided information on how one's demeanor could affect the other's perceptions. They gave context to understand attachment styles, and they gave data from which relational dynamics could be inferred. Attachment theory was incorporated to understand how oneâ&#x20AC;&#x2122;s inner development could be connected to relational experiences in adulthood. Thus, attachment theory provided a rich context for studying each participant as they relationally affected the treatment dyad. Relational theory provided a framework to think about the interactions that were found in the chronic pain setting. It created a space to explore each participantâ&#x20AC;&#x2122;s experience of their counterpart. Combinations of any two attachment styles can result in certain patterns of communication, which impact the relationship. New information that this study hoped to obtain included an understanding of the influence of attachment styles found in chronic pain patients and chronic pain physicians. The resulting analysis of the data depicted several areas that could guide the development of later studies that can investigate whether certain attachment style combinations produced effective treatment relationships.

Research Questions This study explored how attachment styles impacted the treatment experiences of both the chronic pain patient and physician. It observed what kind of attachment styles were present in the participant population. It examined the relationship dynamics that were present in chronic pain treatment.

Theoretical and Operational Definitions of Major Concepts •

Attachment Style: Based upon the work of Bowlby, Main and Ainsworth, a description on how an individual copes and adapts when experiencing danger or threat (Simpson, 1998).

•

Chronic pain: Pain (an unpleasant sense of discomfort) that persists or progresses over a long period of time.

•

Patient: Person that has been diagnosed with chronic pain and has been managing it for at least one year.

•

Perception: A way of regarding, understanding, or interpreting something; a mental impression.

•

Physician: Medically trained professional that provides treatment for chronic pain.

•

Relational Matrix: Basic unit of study consisting of an interactional field within which the individual arises and struggles to make contact and to articulate himself (Mitchell, 1988).

•

Relational Model: Psychological perspective that humans are shaped by and inevitably embedded within a matrix of relationships with other people, struggling both to maintain ties to others and to differentiate from them (Mitchell, 1988).

Chapter III

Methodology Research Strategy The literature review suggested that the multidimensional biopsychosocial experiences of chronic pain physicians and patients were relatively unexamined areas. As such, developing an appropriate method to explore these elements required openness, flexibility, versatility, curiosity, and receptivity. This section outlines the technical steps that were taken to conduct the research.

Study Design This study used a mixed model design that investigated the biopsychosocial elements in a collective manner. It was necessary to explore both qualitative and quantitative information regarding the physicianâ&#x20AC;&#x2122;s experience as a caregiver, and the patientâ&#x20AC;&#x2122;s experience with chronic pain. For example, the attachment style and experience of the chronic pain physician (which was collected in qualitative and quantitative forms through interview and an attachment assessment tool), were analyzed to see if there are any trends in those that chose a career dedicated to treating chronic pain. Tashakkori and Teddlie defined mixed model studies as â&#x20AC;&#x153;studies that are products of the pragmatist

paradigm and that combine the qualitative and quantitative approaches within different phases of the research processâ&#x20AC;? (1998, p. 19). Their description of the process acknowledged both single and multiple applications within phases of the study. Taking this helped provide a comprehensive picture of the relationship. These aspects were reflective of the concept of triangulation, which Tashakkori and Teddlie attributed to the rise of mixed methods (Tashakkori & Teddlie, 1998). In particular, Denzinâ&#x20AC;&#x2122;s identification of four basic types of triangulation suggested the power of combining data sources to study the same social phenomenon. This study design was an example of theory triangulation (multiple perspectives to interpret the results of a study) and methodological triangulation (the use of multiple methods to study a research problem) (Denzin 1978). While mixed model studies offered several ways to obtain a comprehensive understanding, they also lended themselves to complexities in making design choices, which had the potential to cause confusion as a result of the complexities (Tashakkori & Teddlie, 1998). Tashakkori and Teddlie summarized Greeneâ&#x20AC;&#x2122;s work, which identified the five purposes of mixed methods studies. They were: 1. Triangulation, or seeking convergence of results, 2. complementarity, or examining overlapping and different facets of a phenomenon, 3. initiation, discovering paradoxes, contradictions, fresh perspectives, 4. development, or using the methods sequentially, such that results from the first method inform the use of the second method, and

5. expansion, or mixed methods adding breadth and scope to a project (Tashakkori & Teddlie, 1998). These purposes helped guide the design of this study. The study was reflective of the parallel/simultaneous mixed method design, in which the quantitative and qualitative data were collected at the same time and analyzed in a complementary manner(Tashakkori & Teddlie, 1998). This approach generated numerical and narrative data that answered similar questions (Tashakkori & Teddlie, 1998), which aligned with Green’s purposes. There was collaboration between the data. Patton identified three components to “methodological mixes”: 1) design (naturalistic inquiry or experimental), 2) measurement (qualitative or quantitative data), and 3) analysis (content or statistical) (1990). Tashakkori and Teddlie expanded upon Patton’s three dimensions for classifying mixed model studies. This study was an exploratory investigation, which embarked without a priori hypotheses. There were no hypotheses of correlations between attachment styles and relational dynamics. The experience of suffering from chronic pain and/or treating chronic pain was qualitative data. Self-reported qualitative data was collected to help understand the experience (i.e. length of treatment relationship and how a patient feels about their treatment relationship). The analysis of the data also used both qualitative and quantitative methods, such as categorical-content narrative analysis to examine the themes of the qualitative interviews, and attachment assessment analysis to incorporate quantitative data. Based on the work of Lieblich, Tuval-Mashiach, and Zilber (1998), categorical content narrative analysis was the most appropriate narrative analysis for this study, because it primarily investigated an area that was shared by a group of people (making it

categorical), paying attention to the explicit and implicit content of an account (making it content oriented). This method will be described in further detail in the qualitative analysis section.

Research Questions The primary question that this study explored was: Do attachment styles impact the treatment experience of chronic pain for physicians and patients? Sub-questions that facilitated the exploration included: 1. What are some attachment styles found in chronic pain physicians? 2. What are some attachment styles found in chronic pain patients? 3. What is the experience of being a chronic pain physician? 4. What is the experience of being a chronic pain patient? 5. Do any of the above areas impact the treatment of chronic pain?

Sample Selection This study used non-probability purposive sampling. This method was appropriate because there was a limited number of people that met the criteria of the topic being researched (Marshall, 1996). The goal was to recruit ten chronic pain physicians and ten chronic pain patients. The target participants were physicians (residents, fellows, attendings), and patients who had been in chronic pain treatment for at least one year. Only physicians and patients that were over the age of eighteen were eligible to

participate in this study. Participants were recruited through community postings, and emails addressed to various chronic pain support groups and pain centers.

Data Collection and Instrumentation Both qualitative and quantitative data were collected through interviews and questionnaires. Chronic pain physicians and chronic pain patients were asked to complete the Experience of Close Relationships-Relationship Structures (ECR-RS). Participants were asked to do an hour long interview, through which qualitative data was collected. The Experiences in Close Relationships-Relationship Structures (ECR-RS) questionnaire was a revised version of Brennan, Clark, and Shaver's (1998) Experiences in Close Relationships (ECR) questionnaire. This was a scale designed to assess individual differences with respect to attachment-related anxiety (i.e., the extent to which people are insecure vs. secure about the availability and responsiveness of romantic partners) and attachment-related avoidance (i.e., the extent to which people are uncomfortable being close to others vs. secure depending on others) (Fraley, 2011). The questionnaire used nine items to assess attachment styles concerning four relationships. These four relationships were with mother, father, romantic partner, and best friend. The questionnaire allowed for the absences of relationships with mother, father, and best friend. If the participant was currently not involved with a romantic partner, the questionnaire asked the participant to think of their most recent relationship. The items were written so that other interpersonal relationships could be used. In one

study that used the ECR-RS, the patient-therapist relationship was examined. In addition, the items were appropriate for use by a variety of age groups. The creators of this instrument found that the scales were meaningfully related to various relational outcomes, such as relationship satisfaction, and perception of emotional expressions. These nine items were: 1. It helps to turn to this person in times of need. 2. I usually discuss my problems and concerns with this person. 3. I talk things over with this person. 4. I find it easy to depend on this person. 5. I don't feel comfortable opening up to this person. 6. I prefer not to show this person how I feel deep down. 7. I often worry that this person doesn't really care for me. 8. I'm afraid that this person may abandon me. 9. I worry that this person won't care about me as much as I care about him or her. The questionnaire was formatted so that participants were asked to answer the questions for each relationship domain on a Likert scale, ranging from strongly disagree, to strongly agree. 1. Please answer the following questions about your mother or a mother-like figure. 2. Please answer the following questions about your father or a father-like figure.

3. Please answer the following questions about your dating or marital partner. Note: If you are not currently in a dating or marital relationship with someone, answer these questions with respect to a former partner or a relationship that you would like to have with someone. 4. Please answer the following questions about your best friend. Four types of attachment styles could be derived from the instrument. Two scores- one for attachment-related avoidance and the other for attachment-related anxiety, were calculated for each relationship. These two scores constituted the relationshipspecific attachment style. To calculate the general or global attachment style, the scores were computed for each relationship, and then averaged to determine the global anxiety score and the global avoidance score. This method weighed each relationship domain equally. In addition to this method, there was a rendition of the nine questions that were intended to address a general attachment style. This new addition was being tested by Fraley for reliability and validity, and was not used for this particular study. The purpose of this instrument in context of this particular study, was to establish a general attachment category for each person. The categories included: secure, preoccupied, fearful-avoidant, and dismissing-avoidant. The category was not meant to be representative of the physicianâ&#x20AC;&#x2122;s attachment to their patient, nor the patientâ&#x20AC;&#x2122;s attachment to their physician. Participants were asked to complete a paper version of the ECR-RS at the beginning of the session. The paper form did not have any identifying information. The instrument itself also did not require any identifying information. The researcher assigned a unique number to each form for tracking purposes.

The interview primarily consisted of open ended questions designed to capture the experience of the pain physician, and the experience of the pain patient. Physicians and patients were asked different sets of questions. The physician interview included the experience of managing their patient’s chronic pain. This interview was guided by the following statements: Tell me about how you chose to become a pain specialist. Tell me about what it’s like to be a pain specialist. Tell me about what it’s like to work with chronic pain patients. Tell me about how you relate to people in general. Tell me about how you relate to your patients. The patient interview included the experience of managing their chronic pain with their current pain physician. This interview was guided by the following open ended statements: Tell me about how your chronic pain started. Tell me about your chronic pain. Tell me about what it’s like to work with your care team. Tell me about how you relate to your care team. In addition to these open ended interview questions, several closed ended questions were asked to collect quantitative information if the information was not already included through the interview process. The physician participant was asked: How long have you been practicing as a pain physician?

How many chronic pain patients do you currently have? What is the ideal length of time you would like to spend with a patient? What is the ideal frequency that you would like to meet with a patient? How often do you cancel an appointment? How often do your patients cancel an appointment?

The patient participant was asked: How long have you been in treatment for your chronic pain? How many chronic pain physicians have you worked with? What is the ideal length of time you would like to spend with your physician? What is the ideal frequency that you would like to meet with your physician? How often do you cancel an appointment? How often does your physician cancel an appointment?

The interviews took place in a private office. Only one researcher conducted the interviews. The interviews were audio recorded with the participantâ&#x20AC;&#x2122;s consent. The recordings were transcribed, then analyzed.

Qualitative Analysis and Conclusion Formulation Using the software, ATLAS.ti, the content of the interviews was analyzed using the method of categorical-content narrative analysis as described by Lieblich et. al (1998). While relational theory was the guiding theory to understanding the patterns of physician-patient interactions, attachment theory was incorporated to interpret possible relational features, such as enactments that could be understood to perpetuate the relationship. The narrative research method offered a way to organize the early stages of an investigation. As the literature review suggested, a multidimensional approach to understanding the experience of chronic pain was a relatively unexplored topic. The narrative research method allowed the start of the exploration. It gathered information, and the analysis led to the discovery of relevant and impactful themes that could be the focus of future research. This narrative research used â&#x20AC;&#x153;paradigm thinking to create descriptions of themes that hold across stories or taxonomiesâ&#x20AC;? (Creswell, 2006, p. 54). It focused on obtaining a rich understanding of the individual experience. The collection of multiple experiences and their analysis led to the building of themes. Context played an important role in analyzing the information (Creswell, 2006). There was also a sense of collaboration with the participants in narrative research. These were their stories. The narrative method provided access to their specific experiences without challenging them. In addition, the interviews were sometimes therapeutic. The re-storying process helped some of the participants and the researcher gain new understanding of their experience. The interviews of each participant were processed analytically through a process that treated the content descriptively and statistically (Lieblich, Tuval-Mashiach, &

Zilber, 1998). Lieblich et al. summarized the process in the following steps: 1) selection of subtext, 2) definition of the content categories, 3) sorting the material into the categories, and 4) drawing conclusions from the results (1998). The following explores some ways that these steps took shape in this particular study. The interview format in this study was considered to be directive, because it instructed the participant to focus on their experience with chronic pain in particular, rather than asking the participant to provide a complete life story (Lieblich et al., 1998). In a directive interview, all of the obtained text can be taken as the data for the content analysis. While the interview was directive, wider encompassing narratives were also collected from the interview. Thus, it was helpful to think about subtexts, despite the nature of the directive interview. In addition, the subtexts were different between the narrative of the physician and the narrative of the patient. For the physician, major areas of selected subtext included their choice to become a pain physician, the actual work as a pain physician, and their experience with pain patients. For the patient, major areas of selected subtext included the origins of their pain, how pain was experienced, and their experience with their pain physician. Lieblich et al. discussed several ways of defining content categories. One was predefining by theory. Drawing from relational theory and ideas from the literature review, content categories were established as a framework for organizing and analyzing the data. For example, the concept of pain symptoms being treated as a vehicle for communication was a possible category. The meanings of pain was another. Ideas represented by improvement in symptomology was also be a theme. When appropriate, certain inferences were made about actual actions of the participants. These were

sometimes possible enactments, such as the number of calls made to the physician/patient, amount of time spent during the appointment, and method of treatment management. While not the primary theory, attachment theory was also a component of this study. Thus, content categories also included the four attachment categories that were used by the ECR-RS. The enactments in relational theory reflected the behavior patterns of specific attachment categories. Another method of defining content categories was to read the subtext as openly as possible and to define the major content categories that emerged from the reading (Lieblich, Tuval-Mashiach, & Zilber, 1998). Due to the integrated nature of the study across relational and attachment theories, this method was more exploratory and therefore less appropriate in directly answering the study question. This is not to say that the process of drawing from the subtext was completely eliminated, as that certainly occurred, but it was not the primary method of organizing the data. Once the categories were defined, the data was sorted into the categories. Some information was clearly designated to a particular category, while others were sorted multiple times, due to the fact that the content categories existed on a spectrum. For example, some patterns of relatedness reflected a dismissing attachment category, whereas some patterns of relatedness reflected both preoccupied and fearful-avoidant attachment categories. The process of formulating conclusions from results included processing the data in a variety of ways. The content of the interview was also processed statistically, by

quantifying the information through codes, and also by taking the data directly from the transcript (i.e. frequency of contact as reported by the participant). In addition, data from the quantitative portion was used to study whether there were any associations between the two kinds of data that were collected. The question of whether attachment styles impacted the chronic pain physician-patient dyad was explored through this stage of processing the data. Interpretation of the results were validated or facilitated by data that was outside of the selected subtext, and also by quantitative data that was collected. Lieblich et al. offered three main dimensions to consider as these steps were taken. The first dimension asked how well-defined the subtext was to sort categories. As previously discussed, the integrative nature of the study encouraged a more well-defined guideline, rather than a strictly inferential method of drawing from the context. Therefore, establishing a rubric of specific categories to search for, as determined by relational theory and attachment theory, was the most appropriate. The second dimension considered interpretive and impressionistic work. This differed depending on the category of the subtext. Some categories required little interpretive work, whereas others, such as processing enactments, involved a larger amount of interpretive work. Lieblichâ&#x20AC;&#x2122;s third dimension asked whether the data was processed quantitatively or qualitatively. As a mixed methods study, both methods were used. The primary method was to process the data qualitatively, while drawing on quantitative methods to enrich the understanding of the qualitative findings. While the data was highly qualitative, the quantitative data collected was crucial in bringing the study together in examining the

experience of the participant. Findings from mixed methods studies have varying modes of generalizability (Tashakkori & Teddlie, 1998). This study suggested generalizations to specific contexts, such as combinations of attachment styles that could be most effective in treatment management for chronic pain (i.e. if one attachment style required a different style of interaction from the physician). It also suggested generalizations to a theoretical population that may be similar (i.e. applying effective attachment style strategies to other chronic health populations, such as diabetes).

Quantitative Analysis Tashakkori and Teddlie stated that parallel analysis of the two types of data provided a richer understanding of the variables and their relationship, but also that the investigator was limited to one type of data analysis on each subset of data (1998). To maximize the possible insights from analysis, they offered several other ways of analyzing the data. For this study, the process occurred in sequence, so that the results of one part of the study were used to organize the analysis of remaining data. The ECR-RS sorted the participants into attachment categories, after which group trends were observed.

Measures of association/relationship were investigated to see whether there

were relationships between attachment categories and the variables that were collected. The challenge with this aspect was that there was no normal population to test differences between group means, such as a control group. However, it was possible to test differences between group tendencies of different attachment categories.

Statement of Assumptions The following are a set of assumptions that were made when designing the study. 1. Every person has a general attachment style. 2. The ECR-RS is an accurate measure of oneâ&#x20AC;&#x2122;s general attachment style. 3. Attachment systems are activated in the presence of pain. 4. Oneâ&#x20AC;&#x2122;s general attachment style affects how they manage dynamics in their relationships. 5. Attachment styles impact relationships, including the chronic pain physician/patient relationship. 6. The chronic pain physician/patient relationship has an impact on the treatment/management of chronic pain. 7. Participants will honestly share their chronic pain experiences with the researcher.

Statement on Protecting the Rights of Human Subjects Informed consent was obtained from each of the participants. The written and signed consent included: 1. The purpose of the study.

2. The names of the researcher, the researcherâ&#x20AC;&#x2122;s dissertation committee and readers. 3. Participant agreement to complete one in-person interview with the researcher, which was recorded and transcribed. 4. The limited risk of the study, which covered the possibility of feeling vulnerable to emotional distress in relation to discussing the topic of chronic pain. The plan for responding to feelings of distress was to provide options of pausing or stopping the interview, and offering a referral for psychotherapy. 5. Notice of the participantsâ&#x20AC;&#x2122; right to withdraw from the study at any time without suffering any negative consequences. 6. Procedures for insuring confidentiality including: Privacy during interviews. The researcher promised to not share the identities of participants with anyone. No actual names were used in the dissertation and other identifying information was disguised as necessary. All recordings and transcribed data, identified only by number, were kept on a password protected flash drive where no one other than the researcher had access.

Chapter IV

Results Participant Demographics Ten patients and ten physicians participated in this study. All participants were of legal age. The majority of patient participants were female (70%), while the majority of physician participants were male (70%). All participants lived in a large metropolitan area. Most of the patient participants had been chronic pain treatment for 2-5 years. Physician participants had been in practice from one to over twenty years. Half of the patient participants lived with a spouse or partner at the time of the interview. The majority of physician participants (90%) lived with a spouse or partner at the time of the interview. A majority of both patient and physician participants had children in their home. No participants lived with their own maternal or paternal figure. One patient participant reported living with a business partner, while one physician participant reported living with an in-law.

Table 1. Participant Demographics

Number of Patients Number of Physicians Participants 10 10 Participants by Age Group 18-24 1 25-32 2 33-41 2 42-51 1 52-61 2 62-71 2 72-81 0

0 2 4 3 1 0 0

Participants by Gender Female 7 Male 3

3 7

Participants by Years in Treatment/Years in Practice 0-1 0 2 2-5 6 1 6-10 1 3 11-15 2 2 16-20 0 1 20+ 1 1 Participants by Household Composition Spouse 5 9 Children 6 8 Mother 0 0 Father 0 0 Other 1 1

Experience in Close Relationships-Relationship Structures (ECR-RS) Each participant filled out the ECR-RS. Participants were asked to rate nine items for four separate relationships (maternal figure, paternal figure, partner, best friend). Attachment and anxiety scores for each relationship were calculated from the ratings. By plotting attachment related avoidance and attachment related anxiety, each personâ&#x20AC;&#x2122;s attachment pattern towards a specific relationship was determined (see Tables 2 and 3). The ratings were also averaged across all four categories to determine a general attachment pattern. This method was recommended by the designer of the instrument. All physician participants had a secure general attachment style. The majority of patient participants had a secure general attachment style. Dismissive, fearful-avoidant, and preoccupied attachment styles were found within specific relationships.

Table 2. ECR-RS Results-Patients Attachment Pattern Towards Participant Mother

Attachment Pattern Towards Father

Attachment Pattern Towards Partner

Attachment Pattern General Towards Attachment Best Friend Pattern

Secure

Preoccupied

Secure

Dismissive

Secure

Dismissive

Secure

Dismissive

FearfulAvoidant

Preoccupied

FearfulAvoidant

Preoccupied

Dismissive

Secure

Dismissive

FearfulAvoidant

Preoccupied

Secure

Preoccupied

FearfulAvoidant

Secure

Preoccupied

Dismissive

Secure

Dismissive

Secure

FearfulAvoidant

Secure

FearfulAvoidant

Table 3.ECR-RS Results-Physicians Attachment Pattern Towards Participant Mother

Attachment Pattern Towards Father

Attachment Pattern Towards Partner

Attachment Pattern General Towards Attachment Best Friend Pattern

Dismissive

Secure

Dismissive

Secure

Dismissive

Secure

Dismissive

Secure

Dismissive

Secure

The categories helped organize the narratives. However, charts specifically plotting the calculated dimensions demonstrated nuances within the categories (see Figures 1-10). They featured the spectral quality of the categories. For example, the degree to which one was securely attached in a specific relationship, or participants whose attachments were on the border between categories could be observed. Also, the charts allowed one to observe any tendencies, such as clustering in groups. These findings emphasized the importance of analyzing the narrative data in context of the attachment categories.

Figure 1. Patient Attachment Pattern towards Maternal Figure

Figure 2. Patient Attachment Pattern towards Paternal Figure

Figure 3. Patient Attachment towards Partner

Figure 4. Patient Attachment Pattern towards Best Friend

Figure 5. General Patient Attachment Pattern

Figure 6. Physician Attachment Pattern towards Maternal Figure

Figure 7. Physician Attachment Pattern Towards Paternal Figure

Figure 8. Physician Attachment Pattern towards Partner

Figure 9. Physician Attachment Pattern towards Best Friend

Figure 10. General Physician Attachment Pattern

Chronic Pain Patient-Physician Dyad Participants discussed their experiences of the treatment relationship. They spoke about how their chronic pain was variable and how it was therefore pertinent that treatment was adjustable. They also explored the impact that the physician and patient have on each other.

Variability of Chronic Pain. Participants acknowledged that chronic pain is variable, not only across patients, but within patients as well. For example, pain could vary in intensity, duration, and frequency. (Patient) It's [the pain] pretty much everywhere. It feels, I don't even know how to describe it. It's like I've exercised for a really long time, but, I haven't. Sometimes it's different sensations, it feels like there's stuff crawling on me, sometimes it just feels like muscle burning, sometimes I get numbness. The majority of patients considered one modality, which was medication. Two patients discussed holistic methods- using a combination of exercise, nutrition, and medication as a last resort. These patients stated that their physicians did not explore other modalities. (Patient) Kind of insensitive (laughs a little). He basically said that, medication was the only thing he could do for me. And because I was on so many different ones already- he's the one that prescribed the one that made it worse- and then after that, he was just kind of like, â&#x20AC;&#x153;Well, that's it. I'm sorryâ&#x20AC;?. ********************************************************************* (Patient) The main doctor, I did not have a particularly good connection with. He was very, Western mediciney. You know what I mean? He was very, drugs. Drugs, drugs, drugs. Drugs this, you know, whatever, and then I would bring up things, you know, anti-inflammatory foods. I heard there's now a reasonable amount of research.

High fat diet, in certain ways is not bad, it depends on what the fats are. And he was very old school, probably in his sixties, and the whole calories in, calories out, cholesterol- all the things that were gospel until, what, ten years ago. He, he'd- what's the word I'm looking for- subscribe to. I was bringing up things and he would poo poo everything. ********************************************************************** (Patient) That was just the relationship. You came in, and you got meds. In contrast, the majority of physicians that were in this study spoke about addressing variability by favoring the use of comprehensive treatment models: (Physician) I tell patients, you know, if we can try to improve things with a multimodal approach- medication, physical therapy, cognitive behavioral therapy, psychological modalities, if each one of those interventional procedures, if each one of those can help ten, fifteen or twenty percent, it adds up, and fifty percent improvement is, to me, significant. ********************************************************************* (Physician) I think that the change to come here [physician relocating to a new institution], was based on having the interdisciplinary team that I manage to treat chronic pain much more thoroughly, and what I would say, holisticallyâ&#x20AC;ŚIn prior settings, I would have gone more towards somewhat of a more multidisciplinary approach, trying to use different physical therapists and psychologists, but not having them coordinated in a setting to do so. And so, the attraction coming here was having this team to be able to utilize and treat chronic pain.

Resiliency in the treatment relationship. Both patients and physicians discussed the importance of having a resilient treatment relationship. Some participants spoke about managing disappointment through the course of treatment. More patients than physicians spoke about how sometimes treatment would make the pain worse, or brought on side effects or external stressors that increased their suffering: (Patient) You know, after twelve years of doing this, it's at a point, where I'm just like, you people are wasting my time. And it adds stress because I have to schedule it where I have to deal with work, scheduling, and getting the time off and, I mean, actually I have now, where it's a 7:40 appointment. I have to get up extra early, get out there, so it doesn't interfere with work. So, you know, the interference with work, you know, why I have to do that four times a year, just ridiculousâ&#x20AC;Ś Some physicians brought up the fact that pain is an ongoing process. Physicians discussed the importance of trying one treatment at a time vs. attempting many methods at once. They also spoke about managing their patientâ&#x20AC;&#x2122;s disappointment while also motivating them to participate in their treatment: (Physician) Sure, I try also to be very honest and upfront about our plan, what I think, I've heard the patients say, I try to summarize what I think they told me, so that I make sure that I am understanding what they're saying. And then, try to tell them, in a nutshell, what the plan is, not too detailed so they don't get fixated on something, and say, you know, the ways we can approach are with medication, with a procedure, with

both, if X fails, then we can try Y, and if that fails, we can try this, and these are alternatives that we can incorporate down the road. I don't try to do too much at once. I don't think it ever works that well and you don't know really what's working. So, I just try to be really forthcoming so that they are not disappointed and that they are equally invested and informed, and educated as to what we're treating, why we're treating it, and how we're going to treat it and I try to tell patients that, you know, they should follow, you know the instruction, for their benefit, unless you know, there's something obviously adverse happening from it, which I usually tell them, you're not, if anything happens on this medication, certainly stop it and call. But if I recommend physical therapy, and I recommend a procedure and I recommend medication and they don't do any of those things, and come back to me and say, I'm still in pain, then it's very hard to, to work with that. ********************************************************************* (Physician) I really have to push myself to figure out what I'm going to do for the next, so that's something that I found, like, I end up in a place where I'm like, gosh, why did I, why did I give them all my good ideas that first visit? You know? I would have something, like, look, I've got more ideas and maybe that's me being naive and junior and I should probably change my approach, but Iâ&#x20AC;&#x2122;m like, just one morsel at a time. Keep coming back! I've got more for you. Then years go by and people are like, what have you done for me, because really, at the end of the day, my goal is functional rehabilitation. Which, is tough, when I don't have physical therapists here. We have a pain psychologist now, which is great, so it helps. *********************************************************************

(Physician) First I ask question them- what exactly, why do you feel this way? And then more often than not, they'll tell me that, you've tried A, B, C and it hasn't work. And I'm like, okay, well here's D, E, F. There's a lot of things we can offer to you besides pain. And I usually give them a brief overview of the next step I want to take, and then, steps subsequent to that in case this other thing doesn't work. So they have some idea that, okay, if this doesn't work, it's not the end of the road, I have other things I can offer. So I kind of give them a little bit of hope, a little bit of okay, there's other things, it's not like the end of the line here in the things we can offer. ********************************************************************* (Physician) They [effective physicians] know way more about the patient, their r relationship is stronger, I don't know if that's good or bad, that part, but they do derive way more data from the person because there are times when I can't ask every question, I'm not going to think of every question, so over time we make up for it, week after week I can learn more about that person and what they do and what might be causing their pain, whether there are issues, I think that might be the mechanism. ********************************************************************* (Physician) I guess in some ways, most of us don't know why we end up in what we do, as you start practicing, you probably enjoy some areas more than others, and some areas less, so you gravitate towards what your interests are, and maybe even not knowing them up front, so I think that interests me for learning more, studying more about it as opposed to many other topics. How to interact with patients in the best manner who are experiencing chronic pain, I think, yes, that's, I don't know if you call

it a strength, but that's something I'm pretty good at, and structured, and developed pretty strong relationships with the patients, I think the enjoyable part of it is, you see people regularly over and over again, so you do establish a relationship maybe more than some areas of specialty. Primary care physicians have that relationship, but not a lot of specialists have that much of a continual relationship with patients, which I think is something I enjoy. ********************************************************************* (Physician) It's definitely part of the delivery as well. You have to have a rapport with the patient. You can't have a patient sit in your office and just talk at them. You have to ask them about what's important to them. We have patient specific functional scales. Outcomes like that. If a patient has pain in their lower back, they'll fill out a form, or a back survey, and then they get scored. A lot of those things are very general. But when we start talking about a patient that has lower back pain, who is unable to play, they're unable to swing on swings with their kids. And they want to be able to do that. And that's really impacting their quality of life. The more they can't do that, the further and further down that spiral we go. So identifying that, focusing on that, building that up, um those things are really important. And those things are part of the discussion as well. I do think that it's about making the patient feel comfortable, not just talking at them. Not just telling them what they need to do, and but you also want to tell them why. Maybe they'll be happier with their life and their kids, if they could be there for them, to be able to play with them, and so on and so forth.

Physician impact on the patient. In regard to physician impact on patient, patients most significantly reported feeling like they were not being understood by their physician. Several patients mentioned feeling judged by their physician and some physicians addressed that possibility: (Patient) And it's like, and those times, they didn't even know about my past. Some, it's just that, categorizing. Of judging me before they even know me. ********************************************************************* (Physician) I think oftentimes pain patients come in and they're like afraid that we're going to judge them in some way, or not agree to help them anymore, not give them prescriptions anymore, when in reality, I just want to know exactly what you need, and how many medications you use, or if you can't do physical therapy, why is that? Are you still in a lot of pain? So, honestly, I think, when patients try to cover things up, that kind of frustrates a little bit.

Patient impact on the physician. All patients reported feeling like they were intruding on the physicianâ&#x20AC;&#x2122;s time. Physicians stated that understanding and openness in the relationship made physicians more willing to work with the patient. Some physicians stated that there was a two way impact on the relationship:

(Physician) If you're honest, and you give them time, and you listen to them, they listen to you. You have to give them time. You have to give them time and make sure that you listen to them before they listen to you.

Communication styles. Participants varied in their preferred ways of communication. They were asked to discuss frequency and method (i.e. phone, email, or appointment). Physicians discussed their style of communication and its role in their relationship: (Physician) I do respond to them. I try to, I don't like to leave it for too long, usually when I read it [email from patient], I try to respond immediately. Or definitely within that day. When it's fresh in my mindâ&#x20AC;ŚI usually wouldn't email a doctor unless it was really important, so I try to make sure my patients understand that. And if they don't understand that, and they're just kind of emailing me to email me, then I make sure I have that kind of conversation with them, that we should keep it to pertinent things and emergencies and otherwise, it's best to kind of let things sit until our next scheduled visit, which they usually understand. ********************************************************************* (Physician) Opening lines of communication through email is important too, so that's nice with technology being where it is now versus twenty years ago. We can keep the patient coming and keep them doing the things they need to do despite if they're not getting the outcome they want, it might not match up with what we know is going to

happen. It takes several weeks sometimes to get a change, so keeping that line of communication even through emails really helps keep the forward momentum until we finally get the outcome that we want and not everyone's going to have that outcome. ********************************************************************* (Physician) I respond to that [email from patient], even over the weekend. That's hard. Like weekends or extended holidays, a lot of times, that happens. It partly, most of those times it's an acute patient that we started with that week, and now we have this lapse in time and that lapse in time hurts the care process. It really does, unfortunately. A lot of times I'll get something over the weekend about the patient still being in pain, maybe the pain is worse or they're frustrated with it, or they just want advice, so whatever I do, or I can do, I respond right away. ********************************************************************* (Physician) I'm pretty direct, so I do well with people who come in and say what it is they are having trouble with, or things are not going well, um, but on the other hand, in this patient population there certainly is a lot of emotional and psychological distress, which people can communicate with tearfulness, and other kind of physical signs or ways that they would like to demonstrate that for us without actually being able to say it, which I think for many people those are difficult to say. So I guess a person who is extremely stoic and doesn't talk much is the most difficult patient to try to figure out what it is they need or what to do to help them. After doing it for many years, I think looking at the signs of what's going on, as well as listening to the person, or probably both things have to happen in order to help them know what it is

they're saying or what they want or how they're approaching things tooâ&#x20AC;Śit can be done either way, so some ability to communicate, whether if it is verbally or by or, behavioral patterns is probably the key for us to help take care of a patient. ********************************************************************* (Physician) Some patients come in the first time and right off the bat, they love you, they feel like you're interacting great with them, and then, other patients have their guard up. And I feel that a lot of that comes from, in the pain world, we're not the first people they see. It comes from them having been pushed around and nudged around, and kind of pinballed around a little bit. They've gotten this surgery, they've done that, they've seen this primary care, and yadda yadda yadda, and finally someone's like, you know, why don't you go see this pain specialist for this, because I don't want to deal with you anymore. And so when they come to us in that state, it's like, oh my god, I have so much work to do here, and it takes a little bit of effort sometimes. But for the most part, you know, I feel that you show them compassion, that you understand that you're trying to help them. They tend to open up pretty well. ********************************************************************* (Physician) I think it's all about the first interaction you have with them [patients]. I think, when you talk to the patient, listening to what they have to say, not being judgmental about anything they've done in the past, just being compassionate, showing that you're really concerned about their well-being, about their pain, that you don't think they're faking it, that they have a secondary motive here, that they just want some pain medication, something like that. That you understand, and I think,

talking to them as if they're your friend, rather than you're a doctor-patient kind of thing. I think sometimes that makes patients afraid to open up- “They're above me, they'll judge me, I'm going to be in trouble or something,” so I think leveling out the playing field that “You're here, okay, you can talk to me, I won't say anything, I won't judge you,” is the best thing. And once the patient gets through that first encounter, that sticks forever. But if you come in on the first day, and start screaming, “Why are you doing this, this is all wrong, you shouldn't be taking those medications,” they may come back to you because they may have no other choice, but as far as trust goes, I don't think you'll be able to build.

The choice to practice pain medicine. Pain physicians shared what they thought were factors in the development of their career in pain medicine. Many mentioned an interest in helping others and having compassion: (Physician) How to interact with patients in the best manner who are experiencing chronic pain- I don't know if you call it a strength- but that's something I'm pretty good at. My practice is structured, and I’ve developed pretty strong relationships with the patients. I think the enjoyable part of it is, you see people regularly over and over again, so you do establish a relationship maybe more than some areas of specialty. ********************************************************************* (Physician) During my residency I rotated through pain management and found it really interesting to be out of the OR, and go back to talking to patients again, and

having more follow up and continuity of care with them, besides just dropping them in the recovery room and then never seeing them again. It's extremely gratifying to help someone and see how it improves their life, so all those things kind of really made me interested in pain. ********************************************************************* (Physician) I standardized most of my approaches in medicine because that way when a difficult case comes on and youâ&#x20AC;&#x2122;re stressed out, you're falling back on, so my approach is low risk, low cost, patient has to be informed and participating, comprehensive, and, at the end of the day the patient has the consent. That's all that my approach is. If somebody all of a sudden starts to fall outside of that, my spidey sense goes off, and I'm like, whoa, what am I doing, and I come back to this organized approach. ******************************************************************* (Physician) That's what we do here day to day, having discourse with patients, continuity of careâ&#x20AC;Ś I wasnâ&#x20AC;&#x2122;t tired, I was happy to be there. I was enjoying. That was pain clinic. ********************************************************************* (Physician) It was probably the patient interaction and the fact that you can see the patient in progression from the time they had significant pain to the treatment you do and they become better, so, that's what it was. It was the continuation of treatment.

****************************************************************** (Physician) I really, I really enjoy the balance between talking to patients, getting to know patients, knowing the patient's problems and history, and also the procedural aspect of it. One of the biggest reasons I went into pain was establishing long term relationships with pain patients, seeing how they do long term, seeing how my interventions help them. I just find it rewarding. Most people who suffer from pain are legitimately suffering, and it's not fair to group them all together and say, these people just want strong pain killers. ****************************************************************** (Physician) I'm here all the time, and I see patients over and over again. I happened to know this patient, and I know from past experiences with her, she was a very compliant patient, was very kind of by the book, and would really follow up with what we recommended to her, so I knew something must have happened. And she seemed, when I was talking to her, a little more down, then she normally did. She's usually kind of an upbeat person, and she was more withdrawn, got even tearful during the procedure that she's had four times before. And most of my patients who've had the procedure before, know what to expect, like whenever they might be a little anxious, but not so anxious, where I was able to say, “Did something happen? You can tell me. You know, ma'am, I'm here to help you.” And then finally she told me, “Yeah, my dad died a day or two ago, and I'm in the middle of planning his funeral.” And that's what she said. And, “Oh that, the pain of that, I took a lot of extra medication for that.” And I explained to her that “It's probably not the best indication for your pain

medication, so I wouldn't take it for that reason,â&#x20AC;? but you know, she understood that, and we actually refilled her pain medication. ****************************************************************** (Physician) I wanted that patient connection, that again, which in my mind is the very definition of being a physician.

Patient perception of physician attitudes. Patients shared their experiences of their pain physician. Medication management was commonly mentioned. Some people spoke about the reasoning behind their perceptions: (Patient) Uh, I don't know. It's been awhile. They're [physicians are] the same. They're all just trying to put me on medication, and they listen to my symptoms and what I go through on a daily basis, but I just don't feel like they understand exactly. They'll just say, oh, just be active, and you'll be fine. Something like that. They don't really TRY. ********************************************************************* (Patient) Um, that they don't care, and that, (sighs), how do I put it? One, that they don't care that the pain really hurts, and that the health industry itself don't care, I mean, they don't want to, there are so many people that are hooked on pain medications.

Some physicians spoke about what their patients might be experiencing. The physician would know the patientâ&#x20AC;&#x2122;s baseline functioning so that they would notice a change in the patient. Changes were mostly observed in the patientâ&#x20AC;&#x2122;s communication: (Physician) Well, she lacked the, she's usually not a very emotional person. But she was incredibly emotional. And that was the first cue. And then, the fact that, my resident said it was really hard for him, he had to continue to redirect her to figure out what was going on, and then, the thing that really, that I thought was interesting was, I said, "here's what I think is going on. Here's what I think you should do. What do you think about that?" And her comment was, "well, well, yeah." And I was like, "Ok. What's going on?" Then sure enough, she was upset because she had pain for all this time, she had back surgery a couple years ago, she was hoping things would get better, work has gotten really hard, and the thing that she had been doing because she thought it was helping was actually not helping, so I just think she felt hopeless. I think that's what it is. But it was very clear, and usually she comes in, "Yeah, I'm doing great, how are you, how's work, ok, great", and so it was just, it was markedly different and it's not like a rare occasion at the pain clinic. It's amazing when people apologize when they come to pain clinic. Pain physicians are not the first encounter that patients have with medical personnel. Pain physicians discussed what it is like to manage preset perceptions that have been shaped by the patientâ&#x20AC;&#x2122;s previous experiences: (Physician) The main problem is where people clearly have had doctor-patient interactions that have colored their approach to your interaction with them. Before

they got to me, they were, maybe, call it underserved, in their opinion, and, then, when they come to me they're not so much interested in collaboration, but they're interested in helping me understand how I'm like all the other doctors. So, that ends up being something that I sometimes can overcome. But, I leave it as, again, here are the things I would do for you if you're interested, this is what I would recommend, but again, I need your consent, because I think without that, none of this will work. I need you to believe that what we're doing is modern, and it is with you, with your best interest in mind. The difficult cases are when patients hold their ground, and say things like, "You don't know, it's not your body, you don't know, you've never had pain," where it becomes, they try to make it very personal. One of my patients said, â&#x20AC;&#x153;You know if I was white, you would have given me those pain pills," and I say, "I'm sorry you feel that way." That's, I can't really, argue that, there's very little truth in what you say, but that's an argument of deceit, when you say, so I have those situations, at least once a clinic day, where someone's been sent with, they've been told by another doctor, â&#x20AC;&#x153;You need to talk to Dr. [name of doctor] about that. He'll refill that script for you.â&#x20AC;? And it's like, I've just met this person, and, I actually don't think that's what's indicated. I don't know what's so different between a pain doctor and a dentist, but there's clearly a big difference. You normally don't walk into your dentist office and tell them what a good for nothing he was, and how he doesn't understand your body because you have a cavity, you know? So it's just so strange to me, and I think that it's, part of it also has to do with what we treat in our clinic, which is pain, because it does change people's strategies for communication and ability to listen, so, I mean, again, at the end of the day, it's like, I have to even remind myself sometimes that it's an organic disease of

the nervous system and perhaps this person isn't um, isn't actively trying toâ&#x20AC;Ś It's always driven by the physiology, and what I call, I have to prioritize psychosocial stability above everything else. So if that's not there then, nothing else helps.

Relational Theory and Chronic Pain Patient-Physician Dyad Physical realm of chronic pain. Each patient described the etiology of their chronic pain. Some patients had clear diagnoses, such as scoliosis, or nerve injury. Others had more ambiguous origins, such as fibromyalgia. There were a multitude of symptoms, including headaches, chest pain, dizziness, and back pain. Medication was reported to be a common method of treatment, which had its own physical impact, including side effects and resistance. The management of these areas was a common part of treatment: (Patient) It's much better than everything else I've tried, but it's a narcotic, so, you can get addicted easily, I guess. So I kind of undergo withdrawal if I don't take it every twelve hours. I take it in the morning and at night, so it doesnâ&#x20AC;&#x2122;t really matter if I get dizzy and such... ****************************************************************** (Patient) It's really annoying! One of them was very good. It was [name of drug]. And that lasted a good six months. And it was awesome because I could function almost completely normally with it. Six months. And then I could feel the pain again. And she would increase the dosage, but it wouldn't help much. And, I had to

go off of it and try a different one. I've been on so many. They would change me like every two months, because of non effectiveness, or side effects. ********************************************************************* (Patient) Yeah, the pain meds take the edge off. But they donâ&#x20AC;&#x2122;t completely get rid of the pain, it just makes it manageable. Manageable- my measure of success is, if I can sleep through the night, that's good.

Environmental realm of chronic pain. Patients spoke about the environmental realm of chronic pain. Financial cost and time were common themes among the participants. Physicians spoke about understanding the patientâ&#x20AC;&#x2122;s environment, including their home and work situations. (Patient) Last time was when, let me see, I think probably three months ago. Because it's really very expensive. ********************************************************************* (Patient) It did [medication helped]. But it was an extra three hundred dollars, and the copay was, kind of, which wasn't excessive, but every three months, so it was only effective for three months, so I'm going, I'm going to do this every three months? It just seemed excessive, you know, so I was just like, I don't need it. I'd rather manage it with the pain meds, so... *********************************************************************

(Physician) Understanding there's a lot of factors, like secondary social factors that can affect pain and the stresses at home, work, family, and that kind of stuff, and sometimes teasing that out can help you get to the real source of the pain.

Psychological realm of chronic pain. Participants addressed the psychological realm of pain. Mind-body connections were discussed, such as the relationship between anxiety and pain. Mind-set, hope, depression and stress were some of the areas that were explored: (Patient) I thought I was experiencing depression or something, but, in the recent years, I've gotten into meditation, and I found that actually a lot of this psychological pain stems in my body, starts there, so that has a lot to do with it. ********************************************************************* (Physician) I like that they reach out because even from a psychological perspective, it may just ease the stress, and if the stress is lower, then the pain is reduced as well, so stress and pain are linked, so at least if we can mitigate some of that stress, at least they'll be at ease and give them some ways to manage the pain physically as well. And that helps. That definitely does. ********************************************************************* (Physician) What we find is that there is a neurologic experience with that pain. Signal keeps getting put out, put out, put out, and even if that trigger no longer exists, that pain pattern is still there. So if anything contacts that area, or if anything feels

similarly to what caused that initial problem, patients just begin to feel it again even though it might not exist in the tissues, so I think as we work with them, encourage them, contact them, hands on, that really does help to get past some of that undefined psychological, sort of experience of the pain. They're afraid that if anything touches that area, or moves that certain area, it's going to hurt, and we try to slowly get them through that. ******************************************************************* (Physician) Overall principles in the program are stress reduction, less anxiety, less difficulties emotionally. Forcing somebody to do something they don't want to do is not usually helpful in achieving those goals, as where the team gets to know each person from a different angle, there would be good communication about how to change those things. ******************************************************************** (Physician) A lot of times stress is in that area. It may not be the reason why they're having pain, but it's definitely part of the reason why their pain might be getting worse. ********************************************************************* (Physician) Pain is one of those things, where, you know, I can't see pain. And I can't see anything. And you may have a cut, and we may have the exact same cut, but you may respond differently from the way I do. So, it's very hard to tell. There's no X-ray, I could see terrible MRIs on their back, and I'm like, holy moly, but they say, “I don't have any back pain!” I'm like, “How do you not have any back pain?” Yeah, and then I have patients that have like normal MRIs, but they're screaming in pain. So I think

it's a very subjective thing. I think understanding the psychology behind pain is really important as well.

Components of treatment. Participants spoke at length about the specifics of their treatment experiences. They spoke about what it was like to start a treatment relationship, the tasks that were involved, and how it was maintained. Managing patientâ&#x20AC;&#x2122;s expectations was a major part of treatment. Many participants wished that the pain would completely go away. Others knew that they would have to figure out how to function with pain. Physicians discussed having to reorient their treatment goal towards management. (Patient) It's too late, you can't fix it, all you can do is manage it. So I do stretches, and when I don't do stretches, I notice that it gets worse, so it's something I have to do. ********************************************************************* (Patient) I've learned to not dwell on the pain, which has definitely helped me manage it. ******************************************************************** (Physician) We try to, obviously, we're not fixing anything in what we do, but we try to improve their quality of life day to day, and give them some sort of relief, some sort of reason to live, rather than sitting there writhing in pain.

****************************************************************** (Physician) I think expectations is the operative word. I think that that's one of the big things I try to assess on the initial visit, whether or not they understand that it's a chronic condition and there's no magic wand, and it's not going to be fixed immediately or if ever. And if they understand that, what are they looking for? Are they looking for a quick fix and they expect, "I'm at the doctor's office, I've been to x,y and z doctors, none of them can help me, and now I'm at another doctor's office"? Sometimes they can be very frustrated and feel like, â&#x20AC;&#x153;Well you should know how to fix this, and I want to be told that it's going to be fixed,â&#x20AC;? and so managing expectations I think is a big thing, and half the battle is the patient kind of knowing that this is something thatâ&#x20AC;&#x2122;s not going to be fixed, but if we can come up with one or two things that we can try to make better, you know being functional and have relationships that are improved, are huge to me. Being able to go to school, being able to do activities that they like, getting back to doing those, even if they are in pain, being able to do them. Getting them where they're a little more comfortable doing it, or whatever, allaying that fear. Fear is a huge part of chronic pain. So, those things I think are big, especially when we start a relationship in the chronic pain sector. So, if they don't understand that and they're more frustrated and I don't want to use the word hostile, but more, um, less open minded, then it can be difficult and then, you know, sometimes you see people just not come back, or they come back years later, or go to another physician, but the ones who come in and they say, "I know this isn't going to be fixed. And I know that um, I'm probably going to be dealing with some kind of pain issue for the rest of my life," I feel like that

relationship, our relationship is already, you know, we're in a good starting spot. And I'm also more willing to do what I can, you know bend over backwards to try to help. ********************************************************************* (Physician) We tell them from the beginning, we don't plan to take away all their pain, especially when the pain is long lasting. We tell them every treatment we try to implement, can help the pain, five percent, ten percent. All together, the treatments may help thirty-five percent, forty percent, maybe less. So, it's pretty much setting the expectations for the patients and you know, deal with that. Sometimes we tell them that in order to cope with the pain, they have to go to a psychologist, so we try to refer them, and they're very resistant to the idea, but we're pretty much frank with them from the very beginning. That's what we expect to happen, there's no magic plan to treat the pain, we cannot really treat everything that they come in with. ********************************************************************* (Physician) I think many patients do come in with unrealistic expectations. I just had this patient that thinks I have this magic potion that I'm going to give to you, and you're going to become better. And I explain to them that many of the things we do in our pain clinic are just kind of, fancy Band-Aids, if you will. Kind of cover up the pain a little bit...We kind of cover up the pain so you can participate in physical therapy, so you can become more active in that, and then strengthen muscles, strengthen joints, but many patients think we're just going to fix them up and they're going to be ready to go, or some medication we're going to give to them, so it is a little bit of a disconnect. I think sometimes, other physicians even don't really know

or understand what we do as pain physicians. And they kind of just say, go see a pain doctor, he'll fix you up, or she'll fix you up. So when I see a brand new patient for the first time coming to pain clinic, I always start by asking them, “What brings you here, what have you heard about what we can offer,” just to get our expectations straight. That way, there's nothing unrealistic- “Oh, I heard that you were going to fix everything for me!” “No, no, well, you know, we're limited in what we can do, but we'll do our best to figure out exactly what's causing your pain, and then not only can we offer you medications and procedures, but also coping mechanisms are a big part of dealing with chronic pain,” so it's a multimodal. ********************************************************************* (Physician) I would say that I think with the multiple sort of aspects of treating a chronic pain patient, I think what we do here is we set some parameters and boundaries and expectations. So, patient comes in, we've got a condition that we're treating, and we're going to have certain parameters at the beginning that get tested, outcomes measures, and then we're going to have a middle section where we do the treatment, and then there's going to be another re-exam where we retest those outcomes and see where the patient is as far as progressing, and then we're going to have an endpoint. And sometimes, just having them understand that I don't expect them to get to zero on the pain scale, but one is pretty manageable for someone who's been six or seven out of ten pain for eight months or something. Setting that expectation is helpful and then you get them to realize that it's okay if they have some discomfort or pain, that it's not the end of the world…But to set that parameter, that expectation, is important.

********************************************************************* (Physician) I try to educate the patient. Some patients come in with expectations that can't be met, and I think one of the most important encounters we have with patients is setting expectations and setting goals. [Iâ&#x20AC;&#x2122;m] going to have patients that are more educated and can process that, and some patients that maybe aren't as educated and can't process that. Yes, it can become frustrating to the physician, and it can also become frustrating for the patients. I think it's important to somewhat reach mutual ground, or communicate with that patient at the level that they're able to understand. Physicians described the process of establishing their relationship with the patient. Customization of care started from the beginning. Patients were encouraged to participate in their treatment as much as possible. Starting with achievable goals set the framework. Physicians tried their best to be tactful. They validated the patientâ&#x20AC;&#x2122;s experience while also introducing their knowledge. The process was collaborative. (Physician) I don't just drop the bomb on them. I don't just say, "Well, this is something you're going to have to live with for the rest of your life and that's too bad." Saying things like, especially validating how they are feeling, and saying that I understand that they've been dealing with it for a long time, and it's probably not only that physical pain problem, but now it's something more mental as well, you know dealing with pain for x amount of years, can cause some mood problems, relationship problems and when I say that, usually they'll say, "Yeah, I have noticed that" and I start to say, "Well you know, this is an ongoing process and this is something that we're not going to be able to fix overnight, I'm willing to stay the haul with you,â&#x20AC;? that

type of thing. And then, slowly, I start to introduce that this is something we're just going to have to live with, deal with, and do the best we can with. I usually ask, "What things can't you do that you used to like to do", and if it's golf, a sport or just gardening, I say that's my goal. And I can't tell you I'll be able to help you get back to that in a month, a year, but that's my goal. And whatever we can do to try to get that back, or going to school again, especially that's a big thing. If I see a younger patient, teenage, high school, college, who's missing school because of pain, that's something that is very important to try to get them back to doing. However way, and a lot of times, I will introduce the idea of seeing a pain psychologist or any kind of psychologist. And then, I'm usually very careful of how I do that because pain patients usually get upset. Some patients, especially the ones that are in that first category where they want a quick fix, they'll end up saying, "What do you think, I'm crazy? You think this is all in my head?" And then I go back to the "Just dealing with chronic pain can make you, can make you, you know, be upset, have mood issues and, and other things that uh, sleep issues, and every, you know, everything", so, that's kind of how I go into it. ********************************************************************* (Physician) I know that at the end of the day, I have a couple of goals, which is them leaving informed, that we assess them thoroughly, that they feel that, and they feel that they have an understanding of what we've done. Lots of what we have to do is, we calibrate expectations, and then also make sure that everyone has a plan in place. I've actually started having patients do things like, make lists of the five things they do that help their pain, and tell me, what on that list has been working, what hasn't been

working, and the first two things can't be medications. I have them keep that list with them, in their wallet, or, um, at their desk, or in their car, where, when they get into pain, rather than having low insight, low judgment, and feeling helpless, they just have to remember to pull out the list and do something from the list. ********************************************************************* (Physician) I think an ideal patient is someone who is actually interested in getting better. I think many patients kind of come in, and unfortunately they've been in pain for a long time before they come to see us, and they're hopeless, I don't know, you can't do anything, you can try whatever you want, I don't think it's going to work. But I think patients who are interested in getting better, those who are actively concerned about their health and want to participate in their physical therapy, and want to be proactive about things, patients that are, ask a lot of questions, often are well educated with what's going on, patients that are like that have a better treatment experience. ********************************************************************* (Physician) I always ask a patient, what do you think, do you think I should be doing something differently? Is there anything you think that I should do? Sometimes they say something, and if it's not completely unreasonable, like they'll say, can you give me this cream? I heard this helps, then, okay, that's fine. So I usually kind of oblige. That way, it's a give and take kind of thing *********************************************************************

(Physician) That they just are willing to pull the plug on the stuff that they plan to do that day, and are able to take care of themselves, and I think that's pretty powerful. And that changes, like “Hey, I'm doing this to take care of myself. I'm doing this to take care of myself.” And it's like the first time they've ever taken care of themselves, and they've spent their entire lives raising family, taking care of everybody else and kind of just suffering. Frustration was commonly found in the narratives. While challenging, it was expected. Frustration stemmed from various places; some came from within the treatment relationship, and others were from external stressors. There was also frustration towards one’s own self. Participants spoke about their experience with frustration and how they dealt with it: (Patient) They assess you, but there's really no therapeutic benefit. They don't really do anything to fix the pain. It's actually not fixable at this point, so they just ask you how it's going, how effective the pain meds are, how much you have left, and write you a script and send you on your way. And with the tighter government regulation, it was every two months, but you have to sign a paper saying you'll only go to that [hospital], that you will just take meds, or prescribe, that kind of thing. So you actually sign a document so you don't go- I guess they don't want people bouncing between doctors and piling up meds and you know, sell them or whatever, so, actually that's in the paper too, that you will not sell them, sell your medicine... You have to go back, and talk to them, and what they're really doing is nothing, except counting pills, and writing a script. At this point, it's not, therapeutic. It's just maintenance.

********************************************************************* (Patient) My husband sees me cry quite a bit. I'll just start crying, and I'll be like, I just want to be normal again. I try to keep myself busy. I read, I try and do stuff around the house, chores, crafts, watch movies if I can't move. I know that fibromyalgia can go away, can get better suddenly, or it can be managed, so I just keep thinking about that. ********************************************************************* (Patient) I'm personal with them. I know they kind of hold control of my situation, so I don't let on that I really don't expect anything from them. I'm not going to sit there, tell them fiction to get drugs, but I also have to talk to them about things. I really think this is what's going on. ********************************************************************* (Patient) I don't expect that anybody else is going to be much different. I think, part of it is, it's a routine now, and you know, at some point, it's a manageable routine that I just, I've figured out the rules and I've figured out how to deal with the routine, that's good enough, you know, that kind of thing. ********************************************************************* (Physician) I would think that if you stay with doing this, then you probably have or have to develop those skills because otherwise you would be very frustrated with managing this population because you want to see immediate success and gratification as a physician. Managing a chronic population of people who aren't

going to get any better is quite different than people who picture themselves as the saviors of somebody, and they're going to build that on a white horse, and change the world for them, and that's not my expectation of what I'm going to be able to do. Participants described the experience of having an ongoing treatment relationship. Chronic pain treatment is open ended. There are no set formulas; everything is adjusted according to the patientâ&#x20AC;&#x2122;s report. (Physician) It's interesting because some people I give my recommendation and they're like, that just doesn't work for me. I understand, well, let's see if we can find something that works for you. Sometimes, that's a means for them to try to get a fast food version of my expertise, which I just, I can't reallyâ&#x20AC;Ś If I had it my way, every patient would see a pain psychologist, and have a home exercise program on a daily basis, and doing things that keep them engaged with society and interpersonal relationships, and then, the medications are all secondary to that. Medications are meant to enable those processes, to get to your painful psychology. So that's why I consider my role, kind of like, I'm the spring board to all of that, I'm the enabler of that good, but I'm not the end all be all of their pain. I'm not curing them. ********************************************************************* (Physician) They [patients] get frustrated and I try to keep them realizing that all right, this is a process, just kind of have to figure out what is going to work to get you better, people get frustrated when their back hurts, 8/10 for two weeks in a row, they get concerned, but sometimes it takes awhile to actually get the outcomes and you have to

figure out what types of methods are going to be most effective. ******************************************************************** (Physician) Sometimes I'll walk into a room and a patient wants to be very, upset. Maybe not with me, and I'll let them vent, but at a point then I do something that I usually don't do, which is, I sort of redirect the conversation, whereas with other patients, they don't really want to talk, my open ended questions are equally not answered. It's just so interesting, I had a patient today. You know, same thing, I was like, who is this person? This is a very different person who's clearly not doing well compared to the person I've seen for the past two years. And it was, it was different in the way I had to communicate, in order to get the answers to the questions, to figure out what to do next. ********************************************************************* (Physician) I think there are variations, depending on their stability and their treatment regimen. Regular follow up in some manner and structuring how we see them is something good for the patients, so even if they're having a tough time, they know that they're coming back in a certain time frame in the near future there. Not always looking or calling to come in more quickly, but they know that they'll have the ability to try to work through something when they do come in. ********************************************************************* (Physician) A lot of times they'll [patients will] say, “This medicine is not working, it's not working,” so I’ll say, “It's not working, okay, well then let's wean it and go off of it and see,” and they'll come back a couple months later and say, “I'm much worse not

being on it. I didn't realize how much it was helping me.â&#x20AC;? So, I think, if they get in that mind set of "nothing's going to help me, nothing works," it's kind of a selffulfilling prophecy and you have to try to get them to, it's huge, it's just a human thing. Both patients and physicians acknowledged that trust was an important part of their relationship. Trust impacted compliance and resistance in the relationship. Participants discussed how they built and managed trust in their relationship. (Physician) Again, the first thing in the compliant patient, is the patient-physician relationship. If you have a bad relationship with your patient, your patient is never going to be compliant. ******************************************************************** (Physician) The main difference seems to be compliance with what we recommend and going with that versus having their own personal viewpoints skew how they go about, react to what we tell them, or recommend for them to do, so, that's kind of good vs. bad in general. ****************************************************************** (Physician) If they're compliant, we can teach them what to do, they do it at home, they come in again, we get them to advance. ***************************************************************** (Physician) I feel like, very few people get upset. In fact, my experience is that they like you if you treat them nicely, that's what I tell them [the residents]. I know that I cannot cure the pain, but one thing I can give them is respect, and in time, that's all

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they want. It's not about being cured. They know that too. So they just want to be heard, and that's what it is. I think if you treat them mechanically, they don't care. ***************************************************************** (Physician) Developing a trusting relationship. Really, because that's the only way patients can succeed, or youâ&#x20AC;&#x2122;re going to succeed in managing them.

Relational Models of Chronic Pain Patients spent some time describing how they understood their chronic pain, and what it meant to them. Themes of loss, sadness, and change were prevalent. Some patients described the disappointment that resulted from not being able to eliminate the pain. Others described their process of accepting that chronic pain might never completely go away. (Patient) What you said about [running] brightening me up- that really resonated with me. I think throughout the day, I'd be very quiet, at school, in class or whatever, but afterschool, in practice, I'd become this exuberant person. And I think, it had to do with how I felt, and then I didn't. I have I have all these memories of so long ago, and I don't think I'm completely idealizing it, but it is something that is so distant. ********************************************************************* (Patient) I think part of it is internal. Part of it is sorting through something that isn't a physical, neurological problem as opposed to something that is just in my mind. Because sometimes I think it's just me, especially when ability is up and down.

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Because when I can do something yesterday, but can't do it today, and I can do it tomorrow, then you really begin to wonder about your own insanity. And that I think for me is the most frustrating. And I think it's the most frustrating for people who deal on a close level with me. Like I know my business partner sometimes gets really impatient with me because sometimes she'll want to do something, but I forgot what she had asked me. So that can be frustrating for both of us. Because it's hard for her to understand how sometimes I can function so well and sometimes, you know, it's just, it just isn't there. Pain does that too. When the pain is less under control, my ability to focus on other things is more impaired. ****************************************************************** (Patient) I think the way I think about pain, describe it, is inconsistent with how I did, and I felt like more of an open dialogue would be good. I think they are, they are also in a tough situation because they're required to enter all this stuff in the computer now when you go see a doctor. They're pretty much standing by the computer, and it all leads towards diagnosis, medication, and you know, follow up, and they have to enter all this information, some of them even go as far as to tell you, you know, I'm just covering my ass. It just shows you how the medical system is. I think that the problem may be coming from all the people who sue. So there's compassion for everybody, but I think the issue is, it's just a very impersonal thing, and I think you're onto something here, about how my ideas of pain would change, but I think that the problem is, they're doctors. They went to this college where they were taught to think about things based on the germ theory, or whatever. And it's just, research has proven

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that it's not always correct. Actually, if you change your mind, it affects your whole body, and, it's my opinion. ********************************************************************* (Patient) I started to ease into it, I'm going to feel the pain anyway, I might as well not, don't try to prevent the pain, but go with the pain. And, I think that helped to a certain degree. ********************************************************************* (Patient) As I was reading these blogs, about meditation or whatever, you really learn that itâ&#x20AC;&#x2122;s, that, it is, the journey. It's how much your mind can play on making things worse. And, don't get me wrong, it's not a perfect cure, but I remember saying a lot, oh my back hurts today. You know. Even when my back hurts now, I don't tell anybody. I just deal with it. It's not like it's on the forefront of my mind anymore. It could be that it's been so long since I've had it, but yeah, I think dwelling on it makes it worse. Just like when you worry about anything, it just gets bigger quite faster, and you just let it go. And the kids are getting older so I'm less worried about it too. They're not jumping on me as much anymore, so. ********************************************************************* (Patient) Yeah, I think I have [gotten used to having chronic pain], it surprises me how much, in a lot of ways, it's kind of become less upsetting, the loss of running and the frustration of trying to come back, and I think to some extent, I have friends, but it exists; it's just always getting replenished, the sadness.

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Helping the patient acknowledge their current state was important to the physicians as well. Mutual honesty, trust, and respect were essential in the ideal physician-patient relationship. (Physician) Yeah, I try to be [direct]. I think that's the way to deliver the information and the best way to manage whatever type of pain they're having. It's the best route if you can connect, and they trust you and respect you, all those things at once, then they're going to be more apt to go with the things that you're saying and then you get better outcomes. ********************************************************************* (Physician) I want you to be honest with me so I have all the information here to help you. If you leave things out, then, you know, and then they usually kind of, “Oh, okay.” I ask them about other drug use, for example. They'll say, “Oh, I don't use any drugs.” But their urine test will be positive for something. And I'll say, “Well, how do you explain this?” And they're like, “Oh yeah, maybe. And I'm like, “Well you told me, and I’m not going to call the police and tell them you took this stuff, but it affects what kind of medications I give you, it's for your own safety here.” Usually most patients will laugh. And there are patients who distrust us as well. And it's partly our fault that they don't, but they don't have a lot of trust in us. Both physicians and patients acknowledged the ambiguous nature of chronic pain. It was something that was felt, perceived. It was amorphous in a way that escaped all attempts to eradicate it. It was something that could not be pinned down, defined, and ultimately cured. It was often not understood by others.

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(Patient) Mainly because it's hard to match it with anything I felt when I was normal. Um, so to try to describe something to them, that they won't understand fully, is kind of difficult. It's kind of like describing a color to somebody who's never seen it before. (Laughs). It's frustrating. (Laughs more) ********************************************************************* (Physician) I actually thought that pain was still a little bit amorphous, and it really came more, came back to individualized medicine for patients, and that outcomes were very much dependent on how comprehensive you can be in terms of recognizing not only the pathophysiology, but also the psychosocial sphere in which it was occurring. ******************************************************************** (Physician) I wasn’t tired, I was happy to be there…That was pain clinic. Find more on what it was. Like it not being the patients’ fault. They weren’t doing it to themselves.

Impact of Attachment on Dyads The narratives provided information on not only what their needs were, but how each person functioned to meet those needs. The participants described their processes. Some handled the task alone, while others sought to find help, both professionally and socially: (Patient) They basically said, "You have to find a toxicologist.", and they kind of left me on my own. And I called a couple of toxicologists and never received a call back.

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******************************************************************* (Patient) I wish they suggested other doctors I could possibly go to, and they're researching somebody that could actually help me. Otherwise I'm on my own. ********************************************************************* (Patient) I'm pretty open and honest open about everything with my doctors, and I feel like the last episode kind of just blew it all; he had that kind of attitude. ******************************************************************** (Patient) I did a lot of research on my own, you know, what pillows to use to elevate the feet, different stretches to do before you go to bed. So that was all, that I took a very active ownership, of my own. The discussion of their processes led to descriptions of their attachment styles. Participantâ&#x20AC;&#x2122;s attachment styles would surface from the narratives, as they spoke about their experience in having chronic pain, and how it impacted how they related to other people. (Patient) Long and very frustrating. Um, I've been to a lot of specialists to try to rule out any other kind of diseases or whatever, and they, pretty much came to a point where they couldn't help me anymore. They kind of just, passed me off. It's been a little frustrating. *********************************************************************

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(Patient) That actually depends upon how things have gone between one session to the next. If I've been on a fairly high, when the maintenance is working fairly effectively for most of the time between the sessions, we may not focus too much on that. If I've had a lot of frustration between the two sessions, then we tend to focus more on the frustration of [the fact that] I couldn't do anything yesterday because I went to get out of bed and my knee collapsed. So, it depends upon how things are going, which is one of the reasons why in the beginning it's so important to have frequent sessions, because otherwise a lot of that may be lost. If the sessions aren't frequent enough, you may, or I may go through a very frustrating period, maybe during the first, well maybe the first will go well. The second month may be extremely frustrating. And then the third month right before I see the doctor is going well. Then in between months, they kind of get lost in the shuffle. So, until the doctor knows you well enough to know the ups and downs, and can identify some of the things that may be causing it. It's the frequency, I can't overemphasize how important that is. ********************************************************************* (Patient) Sorry, it's hard to remember back. I think with a lot of the doctors and physicians that I saw, it felt very much, like maybe they're weren't taking me seriously, like they thought it would pass, and of course, I had a lot of second guessing myself, like is there really something going on, like how much of this is in my head... ********************************************************************* (Patient) I think I had expectations, but also, I'm not going to get anything out of this, and I think that it was nice that the doctor had this great bedside manner, but I think it

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was also frustrating for me because it was very short, like, maybe like five or six minutes and he just kind of wrote me this prescription to get another MRI and going in, I said, â&#x20AC;&#x153;I don't want more tests!â&#x20AC;? But then when I was with him, I was like, oh yeah, this makes sense. And afterwards I just felt like it doesn't really square with my values, it doesn't square with beliefs I have about like medical tests in general. ********************************************************************* (Patient) I know I was frustrated. Like I told you, my cousin had to come stay at my house for awhile. And then it was just frustrating. I couldn't do anything, I mean, I [had]to call my cousin to go to the bathroom! This is crazy! You know, so, I was just frustrated. I was like, why is this happening to me? What did I do to make my back be like this? What did I do to be in so much pain? So during the time, I was pretty down. Physicians described their own attachment styles at work. They were engaged with their patients, being thorough and using every detail they could access. They were attuned to their patients so that they would notice changes. Addressing the changes was another level of understanding the patientâ&#x20AC;&#x2122;s experience of pain. (Physician) We can look at what was the difference between last month and this month. Is there a difference in the diet? Was there a new medication added? Was there a difference in weather? What are the various, were there other components? Was there a particularly strong stress factor, because stress can affect the pain too. So were there stress factors? What was going on? Because all those need to be

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addressed when you look at, â&#x20AC;&#x153;Is there this huge difference between one period of time to the next?â&#x20AC;? ********************************************************************* (Physician) With the chronic pain patients at the clinic, I let them talk moreâ&#x20AC;ŚI think a lot of chronic pain people come into the clinic just for kind of, just want to talk it out a little bit. They need to vent to somebody, and they might not have someone at home, or I think sometimes just talking about things. A lot of times patients don't expect you to do something. They say, just listen to me. I don't need you to do anything for me per se, just listen to what I have to say. So I think that, I've seen that many people are frustrated, many times we've tried something that hasn't helped, and they get frustrated, so go ahead, vent, vent. Do it to me. So I listen a little bit more, and I let them do most of the talking. ********************************************************************* (Physician) Well, it can be really frustrating. Um, but it can also be rewarding for the patient. I think the same thing happened with me, I think the hands on aspect is really important, and I think that's something really unique to what we offer, is that it's hands on. And I think that people who have an association or a connection psychologically to their pain, um, when you have your hands on your patient, it does change that perception of, you know, what a certain tissue injury, say soft tissue injury, is painful for a period of time that um, what we find is that there is a neurologic experience with that pain. Signal keeps getting put out put out put out, and if that trigger no longer exists, that pain pattern is still there. So if anything contacts that area, or if anything

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feels similarly to what caused that initial problem, patients just begin to feel it again even though it might not exist in the tissues, um, so I think as we work with them, encourage them, contact them, hands on, that really does help to get past some of that undefined psychological, sort of experience of the pain, um, and they're afraid that if anything touches that area, or moves that certain area, it's going to hurt, and we try to slowly get them through that.

Field Notes Impressions and experiences were recorded after each participant interview. Each interview had a distinct emotional feel, rich with nonverbal cues. Patients that struggled with their pain treatment process expressed strong emotions. One patient was wrought with much sorrow throughout the interview and took several breaks as she managed her tears. When asked if she wanted to stop the interview, she replied that while it was painful to speak of her experience, she also found it an important opportunity to share. This idea was echoed by a majority of the patient participants. Each patient participant had contacted the researcher because they felt that their sharing would make a valuable contribution to the chronic pain community. Interestingly, by the end of the interview session, many were surprised by how the interview process itself was a therapeutic experience for them. They did not realize that they would benefit from the process. Some patients reported that they had never shared any of their experience with anyone. When asked if they would have found it beneficial to have shared the same thing with their medical treatment team, they thought it would be ideal, but unrealistic. They felt

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that the actual encounters with their physicians did not promote such interactions. Overall, patients appreciated having a voice in this matter. The impressions and experiences with physician participants were somewhat different from the patient participants. The majority of physicians felt very welcoming, but scheduling was difficult. Two physicians had to reschedule the interview at the last minute. One had forgotten, while the other had a procedure that took longer than expected. The majority of physicians spoke very fast, which made their interviews feel rushed, even though they insisted that they had time. One physician felt defensive, limiting their answers to generic, safe descriptions. Other physicians were very detailed. One was rather flat in affect, speaking very matter of factly, while another cracked jokes and giggled every so often. As such, there seemed to be more variation in physician communication styles. Except for the one defensive physician, the rest of the physician participants were forthcoming in their narratives. The majority of physician participants chose to participate out of their interest in academia and research. A couple physicians were surprised by the nature of the questions, stating that they had not considered certain aspects, but found them quite relevant. In their own way, they too appreciated having a voice in a matter that might have been subtle, but significant.

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Chapter V

Discussion, Implications, and Conclusions The purpose of this study was to get a better understanding of the chronic pain physician-patient treatment relationship. One of the benefits of using a mixed method study was the ability to gain comprehensive knowledge (Tashakkori & Teddlie, 1998) of this relationship. Each participantâ&#x20AC;&#x2122;s narrative was a valuable source of information. Equally as important was the attachment tool (ECR-RS). The results from both measures helped make sense of the findings on a deeper level, which could not have been achieved if any part had been omitted from the study design. It was the integration of both the qualitative and quantitative parts that allowed a way of organizing the information in a significant manner. The narratives provided access to the conscious experience of the treatment relationship. Participants, both patients and physicians, shared how they felt, understood and perceived of their relationship. Common themes surrounding the idea of relating were found throughout the interviews. The interview questions facilitated a dialogue that delved into the participants' experiences, confirming expected themes, as well as revealing nuances that were found to be just as significant.

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The attachment scale provided access to the unconscious. Examining the physician-patient relationship through the lens of attachment styles offered a way to think about the experiences that may not have been considered, but were critical to know. They provided a framework for how a participant might relate, complementing the findings of the narratives. The following is a discussion of the analysis of the data.

The Chronic Pain Patient-Physician Dyad Variability of chronic pain. The variability of chronic pain was demonstrated by both patients and doctors. The patient participants represented a variety of chronic pain illnesses that have an organic component. Some patients were able to identify a specific event, such as an injury, whereas others described a gradual onset, such as bone loss. Chronic pain was often found to be pervasive, leading to feelings of being overwhelmed. For the patient, the affliction with chronic pain was fertile ground for evoking their attachment patterns. They would have to rely on another to fill a need that they could not fill themselves. For both patients and physicians, the constant nature of chronic pain, and its varying degrees of fluctuation, could easily consume oneâ&#x20AC;&#x2122;s energy. It was something that demanded constant attention across multiple realms. Providers responded to this vastness by using multimodal treatment protocols. Physicians discussed the benefits of a well-rounded, comprehensive approach. Physicians would often consider a treatment that included medication, exercise, nutrition, and psychotherapy. Interestingly, patients mostly reported medication as the primary

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protocol in managing their pain. They did not report using a comprehensive method to address their pain. Medication may have been the most concrete and accessible method for the patient to consider. After all, it is self- administered, easy to measure in terms of efficacy, and conventional. For those that are less inclined to work psychologically, it is a quick, simple method. Some patients that were interested in more felt that their physicians did not support alternative or holistic methods. They described most of their interactions with their physicians as being limited to discussion of the medication, getting prescriptions refilled, and reporting how much they were using. Some exhibited anger and frustration towards their “pill counting” physicians, who did nothing else to help them with their pain. The emphasis on these incidents sometimes indicated that it was difficult for the patient to see the potential of their physician beyond their experience with the pills. In short, the pills and the interchange surrounding them, were a representation of what the patient feared an actual relationship might be like with their provider. Trentman et al. (2013) articulated that quality care was signified by time, listening, and thoroughness, and this idea was exemplified by the physicians participating in the study. Interestingly, these are features that are also exemplified by sound parents. Physicians discussed using their appointment times to get to know their patient as well as possible. Many physicians in the study believed that the relationship with each patient was the key component to good medical care, which was aligned with Brown’s beliefs (2003). Physicians understood that these processes required a significant amount of time and felt that they were able to provide time to the patient. Most physicians did not have a set amount of time they spent in their appointments. They found it important to customize their patient’s timely needs, insuring that they got as much time as they

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needed. In contrast, a majority of the patients felt that they were intruding on the physician’s time, and tried to keep the appointment as brief as possible. The discrepancy between the effort put forth by physicians and the patients’ experience of it is intriguing. It suggests that an effective treatment relationship goes beyond customization, time, and listening. These are all essential aspects, but there is more to consider. Mitchell’s processes of relating can be used as a rubric to assess the potential of a relationship. For example, Mitchell mentions investment in a relationship, which includes self-organization, attachment, interpersonal transactions, and the patient’s active role in recreating a subjective world (1988). This process includes finding balance through the interplay between the patient’s illusions and reality (1988). It is not clear whether these tasks are being accomplished in the chronic pain treatment dyad. A physician who is leading may not allow the patient enough space to have an active role. This tendency was shown in some of the narratives where physicians would inundate the patient with information. They would have a plan ready, with alternatives to follow. This could potentially overwhelm a patient who is already taxed and activated in their biological (nervous system) and psychological realms. Thus, the variability of options might be eagerly presented by the physician, but the patient’s experiences might be less represented, and as a result, less well received by or from the physician. If a patient chooses to invest in this relationship, they then are faced with the following tasks of perpetuating the relationship and also getting their needs met. Preserving the relationship is important, because the relationship has become an integrated part of the patient, and a fracture in the relationship would imply a fracture in the patient. Such a fracture would also leave the patient in need without any hope of

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engaging anotherâ&#x20AC;&#x2122;s help. The relationship becomes a part of the patientâ&#x20AC;&#x2122;s relational matrix. Mitchell describes the relational matrix as a tapestry, and it is within this tapestry that the patient is comprehensible (1988). Mitchellâ&#x20AC;&#x2122;s description demonstrates just how deeply woven these parts are: In this perspective the figure is always in the tapestry, and the threads of the tapestry (via identifications and introjections) are always in the figure. (p.3, 1988) Regulation of the self would thereby impact the relational matrix, and the reverse would also be true: the health of the matrix would be intricately linked to the health of the self. This model shows just how profound an investment in the relationship can get, which also explains why patients may be reluctant to connect with their physician. When patients feel little control over their pain and in their treatment relationship, they may be hesitant to then also give up control over a method of self-regulation. In addition, this situation becomes more precarious if the patient has a history of insecure attachments to primary caregivers, because it can trigger past experiences of failed regulation. This possibility depicts the fragility of some chronic pain sufferers. Mistrust and disappointing outcomes can change the relationship as much as relief and cure (i.e. removing the need for the treatment relationship). As a result, patients who struggle with forming a bond with their pain physician may prefer to have a passive role, a loose weaving of these threads.

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Expectations in the treatment relationship. Physicians found it valuable to learn about the patient’s expectations from treatment. Setting realistic expectations and managing the patient’s expectations were necessary, but sometimes challenging tasks. They were unique to this area of medicine, where there was no cure. Patients and physicians both were aware of the patient’s wishes to be back to normal, to be completely without pain, but that it was unlikely. Acknowledging this reality was usually disappointing to patients. As for the physicians, they grew uncomfortably familiar with the burden of failure, which was different for professionals who were used to being successful in their treatment experiences. The path to pain medicine was very selective and was reserved for top students at medical schools.

Impact and communication. The vulnerable nature of the relationship was frequently addressed by the physicians. They often spoke of relationship dynamics with the patient, acknowledging the significant ways that their patients impacted their relationship. Physicians described customizing their communication styles to match their patients. An ideal relationship was one where the physician could follow nonverbal cues and notice a change in how their patients communicated with them. The nonverbal exchange is part of the implicit way of being with another. It is developed through early attachment relationships, and is representative of the emotion emerging from the body which cannot be communicated otherwise. This level of awareness would better facilitate a genuine discussion on how

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that patient was managing their pain. It was a process that would nurture compassion and understanding, which helped steer treatment in the right direction. Physicians often mentioned this aspect as being fundamental to their choice to become a pain physician. They found satisfaction in the long term relationships with their patients, which was often absent in many other areas of medicine. Pain medicine was different from primary care in that it was specific to pain, but it was different from other specialties in that it was long term. Physicians valued the continuity of care in their work. Perhaps it is this difference that produced some of the negative patient experiences. Some patients expressed dissatisfaction with their physician, feeling that their work together did not amount to much. Some patients felt that their physicians did not care, or that they did not put in enough effort. If patients were correlating care and effort with change in symptomology (i.e. the eradication of pain), then it is likely that patients felt that their pain doctors were doing nothing for them. Lincoln et al. (2013) suggested that there is a discrepancy in the expectations across medical fields and patients, and this phenomenon was supported by the findings. Physicians felt that some patients, and even some professionals in other medical fields, put their hopes on the false expectation that pain physicians were supposed to take away their pain and get the patients back to their normal state. These examples of dissonance and ambiguity may help explain why the chronic pain dyad is less explored (Trentman et al., 2013). There were gaps in what the patient experienced and what the physician intended, but they were not obvious. However, analyzing the narratives in context of each sideâ&#x20AC;&#x2122;s experience revealed how much was

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being lost, how much was not being used. The narratives also showed how possible it was to strengthen the relationship, if only each side could see the other.

Relational Theory and Chronic Pain Patient-Physician Dyad Physical, environmental, and psychological realms of chronic pain. There are many possible explanations for why this gap between physician goals and ideals of practice and patient experiences would exist. The findings could be explained by relational theory in the chronic pain patient-physician dyad. Perlman (1996) observed physical, environmental, and psychological causes of chronic illness. These areas were present in the narratives of this study in an interconnected way. For example, medication in chronic pain treatment was a topic that impacted the patient in each realm. On the physical side, pharmacology and physiology determined the efficacy of the medication. On the environmental side, aspects such as cost (i.e. time and financial) and access impacted the patient’s experience of the medication. These areas would also affect the patient’s psychological experience of using the medication. Reported experiences included frustration, increased stress, shame, and embarrassment. Many patients believed that successful treatment meant getting off of their medication for good. Physicians understood that the weight of these areas would undeniably contribute to the patient’s suffering. This led to the development of treatment protocols that were multi-modal and comprehensive. Physicians would need to assess the patient’s suffering on physical, environmental, and psychological levels. A positive relationship would be

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necessary to access this type of information. Appointments were designed to build the relationships and gather the information. In theory, the appointments would help provide a safe environment where the patient could discuss their needs without feeling shame. However, managing such vulnerability can be a delicate area. In fact, some physicians found that their patients were surprised by their questions, which included social and personal elements. Few patients in the study reported sharing this information with their physicians. When asked why they thought this might be the case, they replied that they did not expect such interactions with their physicians. Some felt that physicians were not interested in getting to know them as a person. Many thought the appointments were to discuss only the medication options. These kinds of expectations could be reflective of the patientâ&#x20AC;&#x2122;s attachment style, as will be further discussed later in this chapter. Relationally, adhering to convention provides some safety by creating emotional distance, and by not risking vulnerability through possible shame in their neediness. They believed that the physician should/would only address the physical causes of chronic pain. This was a puzzling finding, because the patient participants felt that the issues were highly relevant to their chronic pain. As a matter of fact, most of the narrative interviews focused on a combination of the environmental, physical, and psychological causes of pain, and a comparatively small amount of time was spent discussing the physical causes of their chronic pain. Participants found that speaking about the environmental and psychological realms were therapeutic. However, few felt that it was possible to discuss them with their pain physician. This could be seen as patients resorting to their learned behavior of putting away their needy selves. They were not

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aware that chronic pain treatment would include an approach that included the environmental and psychological realms. The patients found it reasonable and hopeful that future treatment would include these measures. They believed that such discussion was reflective of a progressive culture. This is admittedly true, as medical education is changing to incorporate more of the environmental and psychological realms in their training programs. For example, the experience of a more recently trained pain physician was different than the experience of a pain physician who had been practicing for decades. What was interesting was that the pain physicians who were longer in practice had acquired their insight into these areas through extra, optional training. They were seen as being unique to their peers when they designed the comprehensive protocols. Gradually, these areas which were once auxiliary, were now part of the required, mainstream training that newer physicians received. It is possible that the patient culture had not yet reached the same understanding that current physicians were already addressing.

Components of treatment. Despite the fact that current patients did not expect their current physicians to be relational, reinforcing the relationship has been a major component part of care. Physicians spoke of various methods that they found useful. Staying current on medical advances and being able to pass on the knowledge to their patients was important. Physicians encouraged patients to be active in their own care. Care was not limited to listening and being educated. Incorporating the ideas into their daily lives was critical.

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Patients learned that they had agency in their experiences. They would not have to be helpless, which was a problem that McShea found in chronic pain patients (2007). Eagle (1993) offered the use of enactments to understand relationships, and noncompliance was the most commonly found example in the narratives. Trust seemed to be fundamental to compliance in the relationship. If patients did not trust their physicians, not just on a level of competency (relating to the physical realm), but also in personal attributes, they were less likely to be compliant. Thus, if patients found their physician to be cold or less caring, they would be less likely to follow through what they should be doing at home. It would seem as though they did not trust their physician to provide for them, thereby really having no good reason to abide by their instructions. It is possible that while patients do not expect it, they search for relational aspects on an unconscious level. Mitchellâ&#x20AC;&#x2122;s description of the relational matrix, and what it entails (integration and preservation of the connection) may help explain the puzzling occurrence of patients being unable to accept offerings of what they had been searching for. Patients want a personable physician who is interested and caring, and these qualities are linked to successful treatment. Successful treatment may mean fewer appointments, or perhaps even a termination of treatment. This would be a disruption to the relational matrix. The goal of relational theory conflicts with this outcome, because patients have the need to perpetuate their connection to their pain physician. Ending the relationship would go against this goal. There is strife in the aspect that the person who could be trusted to take care of their concerns would essentially go away.

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It was also important for the physician to be able to trust their patients. Physicians had to trust what their patients were telling them about their chronic pain. This mostly became problematic when it came to medication management. Some physicians used pain contracts enforcing zero tolerance for violations. Violations were centered on such concerns as misappropriation, like selling their pain medication, or filling their prescriptions from multiple sources. Physicians were willing to address issues such as the addiction itself, but they would not continue a treatment relationship if the patient was found using the medication for economic gain. Physicians employed tools that were designed to encourage a level of understanding with the patients. They would customize time and communication so that patients felt comfortable and included. They would summarize what the patients said in their appointment to show that they were being heard, and to clarify any misunderstandings. These steps demonstrated the physicianâ&#x20AC;&#x2122;s capacity for attunement. Physicians also found it important to relate on a social level. They stressed showing compassion and empathy. They demonstrated respect for their patients. They creatively sought ways to help their patients convey their experience of chronic pain so that they could understand them better, and hopefully find the best treatment possible. There were strong parallels to how analysts worked with their chronic pain patients, as described by Perlman (1996), Shapiro (2003), and Taylor (1998). By educating their patients, they hoped to increase their patientâ&#x20AC;&#x2122;s understanding of their pain. This is similar to how the analyst works with the client to increase understanding of their inner world. Pain physicians would explore and investigate possibilities with their patients, as would analysts. In both cases, there is investment in the relational matrix.

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Relational Models of Chronic Pain Differing expectations of role. The information gathered from both patients and physicians drew an interesting contrast. To state it briefly, patients believed that the role of the pain physician was to manage their medication. Pain physicians believed that one of their primary roles was to nurture a strong relationship with the patient. It was apparent that the expectations of the participants were vastly different. The patients’ narratives suggested that they yearned for nurturing, but they did not expect it from their pain physician. They did not know if it was acceptable to ask for it, or how they would ask for it. This kind of predisposition could lead to missing the physician’s intentions of cultivating a nurturing relationship.

Psychosomatic personality. McDougall’s theory of the psychosomatic personality (1989) can be one way of understanding the difference. The patients’ narratives were often filled with descriptions of loss, change, or sadness, but they first had a flat affect when speaking. None of the patient participants reported sharing these experiences with their pain physician. In fact, many of them had not shared these parts with anyone at all. Patients found the experiences overwhelming and frustrating to discuss. Some grew emotional during their interview. Accessing these parts required some probing by the interviewer. The process was reminiscent of McDougall’s description. Once their calm, emotionless demeanors were fractured, there was an outflow of thought and emotion. Some patients mentioned

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feeling better and being surprised by how talking about it with the researcher seemed to help. Some acknowledged the ability to lean into their pain as the turning point to managing their pain. They may not have expected to speak with their pain physician about their experience, but when it came to managing their pain at home, they believed that there was a correlation between their openness to feel, and how much more bearable it felt to have chronic pain. Some patients noticed a correlation between how they understood their pain and how they managed it. These findings support McDougallâ&#x20AC;&#x2122;s idea that the presence of emotion is inversely relative to psychosomatic vulnerability (1989). The more a patient allowed an emotional experience, the less likely they were to exhibit psychosomatic symptoms through a physical process. Again, this scenario sets up a conflict. A genuine sharing with the physician, such as allowing the pain physician to see these feelings and emotions, could possibly lead to a treatment that alleviates the pain, which might then lessen the connection between the patient and the physician, which goes against the relational goal of perpetuating the relationship. McDougall also stressed the importance of having access to words to convey oneâ&#x20AC;&#x2122;s experience of the dyad (1989). Some patients found difficulty in describing their pain symptoms. Their pain was vague, ambiguous, beyond the typical word, but profoundly present. They could not find the words to describe their experience justly. Theirs was to be felt, as the researcher was able to feel the heaviness of their burden, but it was rare that this kind of experience could be relayed to their pain physician.

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Perpetuation of the dyad. The more accessible mode of communication in the dyad were the appointments, the talk that patients expected to be limited to medication. These visits were also routine, which is congruent with Mitchellâ&#x20AC;&#x2122;s idea that contact is primary to the relationship (1988). The nature of the dyad was deep-rooted, powerful, and sustaining, despite it also being potentially difficult. This made sense when examining the patientâ&#x20AC;&#x2122;s daily environment. Most patients were on disability, or worked from home due to their chronic pain. Their appointment with the pain physician was one of the few routines that they could keep and continue. Perhaps some patients refrained from sharing with their physicians because they were afraid that it would disrupt the relationship that they had. An emotionally shared experience might threaten the psychosomatic personality that ensured the perpetuation of their relationship. The acceptance of chronic pain seems to allow the perpetuation of the relationship. In regard to setting realistic expectations, physicians found this to be the most important part of building their relationship with their patients. Their narratives suggested that they had stronger relationships with patients who were able to accept that their treatment was about managing, not eradicating the pain. This is parallel to the idea of perpetuating the relationship, not eradicating the relationship. Interestingly, most of the patient participants had accepted that their chronic pain was one to be managed, not eradicated. Some mentioned their acceptance of this fact as the turning point in their treatment, where they felt that they had a chance to be themselves, instead of searching for something that may never be found.

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Impact of Attachment on the Dyad Results of the ECR-RS. The guiding question to this study was whether attachment patterns impacted the chronic pain treatment experience. Identifying each participantâ&#x20AC;&#x2122;s attachment style was part of the data collection. All participants took the ECR-RS, which calculated attachment styles in four significant relationships (mother, father, partner, best friend), and a generalized attachment style, which was calculated by averaging the four. In this study, every physician resulted in a general, secure attachment style. Physicians were securely or dismissively attached in the four categories. Patients varied in attachments from relationship to relationship. In addition, it was difficult to ignore that the narratives spanned a wide spectrum. The variety also did not appear to be randomly caused. Examining the data using the calculated generalized attachment styles produced no compelling results, because there were no differences in attachment categories, but there was something causing the differences in narratives.

Attachment patterns towards early relationships. Interestingly, Mitchellâ&#x20AC;&#x2122;s idea that chronic pain could be seen as a way to perpetuate early experiences, resulted in a possibly deeper interpretation of the data (1988). Early experiences were represented by attachments towards the mother and the father, so these attachment styles were revisited. Physicians had either secure or dismissive attachments throughout the different relationships, but patients were more varied in their attachment styles towards their mother and father. As a matter of fact, two

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out of ten patients had secure attachments toward their mother and father, while eight of ten patients had at least one attachment style toward a parent that was not secure. Four out of ten physicians had dismissive attachments toward their mother, father, or both. This finding is intriguing. While the ECR-RS is not customizable to test specific relationships- it cannot be used to actually identify a patientâ&#x20AC;&#x2122;s attachment style towards a physician- it is reasonable to infer a parallel between the patient-physician attachment patterns and the attachment styles that patients have towards parents. The pain physician is the provider, the caregiver, as the parents were during the patientâ&#x20AC;&#x2122;s early years. The pain physician fills a necessary need of the patient, similarly to how the parent fills a necessary need that the child has.

The emerging idea is that chronic pain patients might

be perpetuating their early experiences with their caregivers in their current treatment with their pain physician. Table 4 presents how attachment patterns and relational theory bring a comprehensive understanding to the treatment relationship. It aligns how a patientâ&#x20AC;&#x2122;s attachment pattern towards an early caregiver affects the view of the self and of others. Possible relational dynamics that the patient may be perpetuating are listed, and specific examples found in the narratives to support the attachment pattern driven enactments are incorporated.

Table 4. Relational Theory and Patient Attachment

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Chronic pain physician as a secure base. The narratives seem to support this idea. Physicians, who were all secure, were familiar with treating chronic pain. They spent an average of ten hours a day in clinic, building relationships with different kinds of chronic pain patients. In addition to their clinic hours, they fielded phone calls, voicemails, and emails. They were professionally trained to be experts on procedures and pharmacology. They could be seen as similar to the â&#x20AC;&#x153;secure baseâ&#x20AC;? that Ainsworth used to build her Strange Situation study.

Patients with secure attachment to early caregivers. Ainsworth found that securely attached children displayed equal access to exploration and the seeking of solace when the child felt threatened (1970). Patients who were securely attached to their parent(s) were comfortable with finding supplementary ways to manage their chronic pain, such as doing research on their own and then bringing the information to their physician for discussion. These patients were comfortable expressing what they needed from their physician. They preferred to have an equal, collaborative partnership with their pain physician.

Patients with fearful attachment to early caregivers. Patients who had fearful attachment patterns towards their parent(s) tended to have more of a detached treatment relationship. These attachment patterns correlated to Mainâ&#x20AC;&#x2122;s disorganized attachment category. These patients were comfortable seeking

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outside resources that were not always supplementary, but methods that would decrease their contact with their pain physician. For example, one patient preferred to manage his chronic pain by learning how to meditate, and would keep his pain appointments to a minimum. Their encounters with their pain physicians were brief, simple, and not deeply involved. This was parallel to Ainsworthâ&#x20AC;&#x2122;s finding that disorganized, insecurely attached children would seek alternatives to their base (1970). The patientsâ&#x20AC;&#x2122; narratives also alluded to ideas that they thought they might be unlovable by their partners because of their chronic pain, which is a pattern that is found in disorganized and insecurely attached children (1970).

Patients with preoccupied attachment to early caregivers. Preoccupied attachment patterns were found towards maternal relationships in some of the patients. Bartholomew et. al (2007) described that children with preoccupied attachment styles often displayed a negative model of the self, and a positive model of others. Interestingly for these patients, their narratives frequently visited the idea of something being wrong with them because they had chronic pain. The meaning of chronic pain treatment meant finding out how to feel normal compared to others. They were comfortable seeking the help of others, asking their pain physician to educate them at a level that they could fully understand.

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Patients with dismissive attachment to early caregivers. Patients who were dismissively attached to one or more of their parents also showed independence, but with a positive self-model, which is aligned with Ainsworthâ&#x20AC;&#x2122;s avoidant insecure attachment style (Brennan, 1998). These patients were perhaps the most separate from their pain physicians, often using their own research to challenge the physician. Their narratives included weaning themselves off their medication, and making treatment decisions without consulting their physician. Furthermore, their narratives even suggested a certain amount of disdain towards their pain physicians.

Presence of secondary attachment strategies. The associations between attachment patterns and narratives lead to many possibilities in understanding the chronic pain treatment relationship. Patterns can even be observed from the interviews when examined from the research process. For example, patients who were either securely or dismissively attached to their early caregivers had the longer interviews. They spoke most in-depth, producing more narrative from which excerpts could be chosen. They appeared to be more comfortable speaking about their experiences, and contributed evenly to each area of questions. This was an interesting contrast to patients who had preoccupied or fearful (disorganized) attachment patterns to their early caregivers. These patients provided in-depth descriptions about technical aspects of their treatment (i.e. providing a timeline, steps of the treatment, pathophysiology of their chronic pain), but said very little about the relational aspects of treatment. This could be understood as the patient continuing to leave the relationship

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untouched by the dialogue. Perhaps these examples mirror the encounters that the patients have with their pain providers and/or early parental experiences. By the same token, the language used by physicians during the interviews also appeared to be associated with their attachment styles. Interestingly, physician participants had either secure or dismissive attachment styles towards specific relationships, while having an overall, general secure attachment style. The discussion of physicians who were secure in all their relationships reflected a higher capacity to empathize with their patients. For example, their narratives would stress the importance of listening to the patient, showing respect, and collaborating with the patient. Their experience would also be more personal, displaying more of a willingness to share with the patient. They could bear the burden of disappointment alongside their patient. In contrast, physician participants who had dismissive patterns towards any of their relationships tended to be distant in their narratives. These physicians were prepared to educate the patient and direct the relationship. Treatment was about the patient following the physicianâ&#x20AC;&#x2122;s plan. There was less engagement, less sharing. These attachment patterns impact the relational tasks of investing, perpetuating, and regulating, as discussed earlier. Thus, a physician with dismissive patterns may be putting in a lot of effort, such as in planning and directing, but the relationship may not grow the way a physician with secure attachment pattern might nurture a relationship. The parallels provide a fascinating way to understand why different patients have different treatment relationships with their pain physicians. They also highlight ways that treatment can be customized to strengthen the relationship, to overcome the obstacles that the attachment

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patterns might create, and to ultimately bridge the gap that has prevented both sides from coming together.

Schematic This study explored the current state of the chronic pain treatment relationship. One of the goals was to organize the information and develop an idea that would ease the burden in this particular relationship. The process of exploration revealed that a tremendous amount of influences are present in the relationship, which in itself is a challenge as it is being managed by the dyad. There is a question of what is actually being communicated in the relationship, and what is being lost. It is clear that the patient-physician encounter is not just an appointment where facts are exchanged. The conversation is one that brings together the external and internal information in regard to pain. Pain is subjective. There is no diagnostic tool that indicates a patientâ&#x20AC;&#x2122;s level of pain. It is different from measuring the level of triglycerides or enzymes in a blood panel. Pain is reported by the patient. What information and how it is reported, is crucial. Unfortunately, this study showed that not everything that a patient experiences is always being communicated to the physician.

Likewise, not

everything that the physician considers is being communicated to the patient. The interviews provided behind-the-scenes access to each of their experiences and it was apparent that there was a wealth of knowledge that was missed from the other side. This information was usually something that could have improved the treatment relationship. To clarify, it may not have cured the actual pain, but it could have improved the discussion by addressing impactful areas.

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Physicians were aware of this. Every physician mentioned the importance of the relationship in their interview. Physicians also noted that their emphasis on the relationship is a more recent practice. To that end, the medical field is progressing towards a more collaborative model, bringing forth change in patient care. Their narratives revealed that efforts were being made to the extent of their social capacities. As one physician put it, the most important thing they did was not a skill that they learned in their medical training, but one that their parents instilled in them. They talked to their patient. The ECR-RS and the analysis on attachment patterns showed that attachment patterns do make a difference in how the patients and physicians interact. This is an area that the medical field did not traditionally incorporate, but is starting to consider. For example, primary care textbooks published in 2016 are addressing attachment theory in the medical setting (Strauss, 2016). Knowing a patient’s attachment style contributes to what physicians are already doing in their efforts to build the relationship. While physicians are not expected to assess a patient’s attachment style through their own conversation, the ECR-RS provides immediate access to the patient’s attachment patterns and can suggest the most effective way a physician might discuss treatment with a patient. This lessens the burden of the relationship as it can curb frustrations in miscommunication, or aid the process of deepening the treatment relationship. The study also suggested that the physician’s own attachment patterns influenced the relationship. The attachment patterns of both sides should be considered as the relationships embark on the relational tasks of building and preserving, while providing pain management. Each person’s attachment pattern can be seen as a type of filter, and

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what is available for the tasks of the relationship is a product of what is actually brought to the other person. Figure 1 is a visual schematic of how each of these forces impact the treatment relationship.

Figure 11. Treatment Relationship Schematic

Limitations This was a primarily qualitative exploratory study that included some quantitative measures. It used a non-random sample. Caution must be exercised if findings from this study are generalized to a larger population of chronic pain patients and physicians. The sample size was limited. Participants were from large metropolitan areas. Participants widely varied in biological, psychological, and environmental characteristics. Chronic pain covers a vast field of diagnoses that may alter the findings. Some patient participants had chronic pain stemming from injuries, such as nerve damage

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from an automobile accident. Some patient participants had chronic pain their entire life due to congenital illnesses, such as scoliosis. There were several different routes for physicians to practice as pain physicians. They varied in the phase of their careers. Some were beginning pain physicians, in their fellowship year. Several had been practicing pain medicine for over twenty years. Some had trained overseas before getting their license to practice in the United States. Some were research oriented, and others were strictly clinical. In addition, there may have been certain qualities that drew participants to the study that may not be true for patients and physicians that did not participate. For example, physician participants were more responsive to emails and posting, compared to patient participants. No willing patient participants were found at pain centers. Patient participants responded to postings in generic areas, such as coffee shops. The nature of the design also led to some limitations. The narrative interviews had a tremendous amount of data, and it was not possible to consider every detail or angle in interpreting the data. In addition, all of the information was self-reported, so there was the risk of incomplete or inaccurate information. Some participants may not have been comfortable or unable to discuss certain areas completely. Although the ECR-RS has been found to be respectably reliable and valid, it has never been used to explore the chronic pain patient-physician dyad. Thus, while it was useful for the study, its accuracy and applicability to this study cannot be guaranteed. The combination of relational and attachment theories offered one way of understanding the treatment experience. However, there were multiple theoretical

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perspectives that could also be used to examine this relationship. Object relations or self psychology could also provide useful frameworks to understand the treatment experience of chronic pain patients and physicians.

Implications and Conclusions The findings from this study are significant for introducing clinical social work practice to new, collaborative applications. This study used clinical social work methods to explore the experience of chronic pain. Chronic pain is a physical diagnosis with an ambiguous nature, often having no known etiology, a diverse set of possible symptoms, variable courses of treatment, and an undeterminable prognosis. This physical suffering is also endured alone at times, which is certain to have an impact on one's internal functioning. Physical pain, personal isolation, hopelessness, and other consequences of chronic pain suffering are some symptoms also seen when treating mental health issues. Therefore, psychotherapeutic approaches that are familiar to clinical social work could contribute to a field that is currently addressed primarily by the medical field. In social work, features of one's biopsychosocial environment are taken into consideration to formulate a comprehensive view of the patient's experience. Accurately grasping what it is like to be the patient influences the process of treatment, its progression, and its efficacy. This study used the same approach to gain a comprehensive understanding of the experience of being a chronic pain patient or a chronic pain physician. The field of clinical social work is concerned with many areas of human experience that are relevant to chronic pain management, but this specialized medical area has not been able to benefit. In chronic pain management, psychological information is often available, but

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not usable for the medical team. They may have access to it, but have not integrated it into the treatment protocol for more effective treatment. For example, currently, a psychological tool may be administered to screen for depression and thoughts of suicide, or to screen for substance abuse. It might be possible for an attachment style assessment tool to be administered to gauge the patient’s attachment patterns. The clinical social worker can interpret the results so that the information can be used to facilitate patients’ relationships with the team and enhance the effectiveness of the treatment plan. Social workers are trained to provide the knowledge necessary to assist in bridging emotional gaps between the medical team and the patient. More subtle and extensive information about patients’ psychological needs may require understanding their attachment patterns. By learning how both the doctor and patient function in significant relationships, the clinical social worker can facilitate smoother relational functioning between medical team members and patients. An appreciation for the positive influence of this factor on treatment could also enhance empathy within the team, thus providing a generalizable learning experience. Understanding the mind-body connection can be a valuable resource in chronic pain management. Nonverbal or less well-articulated information can be expressed in body language or in psychosomatic forms. The characteristics of chronic pain, like frequency, duration, or sensation, while they may have organic causes, can sometimes be understood as relaying symbolic messages. Adding the representational meaning of symptoms to the physician’s understanding of the organic etymology of these disorders increases comprehension and creates an opportunity for more beneficial medical management.

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Chronic pain is a physical embodiment of loss and suffering that impacts the patient’s experience of past, present, and future. A body that was once healthy and properly functioning, is now a body that betrays the patient. Opportunity and potential is replaced with constant suffering, and the experience of loss happens repeatedly with every episode of recurrent pain. Clinical social workers are skilled at helping patients cope with loss and suffering. Psychotherapy helps patients deal with emotional experiences. In chronic pain management, psychotherapy can help patients manage the emotional experience of suffering, to understand what it means to “be” with their chronic pain, and figure out how to best live with it. An effective, comprehensive treatment regimen would thus integrate medicine and psychotherapy, and has the intentions of improved treatment, alleviation of symptoms, and development of a capacity for acceptance. Researching the use of clinical social work in chronic pain management puts together the potential bio-psycho-social capacities of clinical social work in a medical arena that could benefit greatly by its inclusion. Clinical social workers may facilitate the efficacy of the medical team’s impact by gleaning information from psychological testing, and comprehending and applying attachment style and relational knowledge to doctor patient dyads. Clinical social workers may also positively impact self-esteem, self-image and self-worth of the patients by helping them understand their experience of chronic pain. Both of these possibilities contribute to the goals of improving treatment, alleviating symptoms, and developing capacity for acceptance of chronic pain. The outcomes from this study offer clinical social workers a new field to apply skills that are already well developed and practiced with success. It leads to an

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opportunity to impact a medical condition previously treated only from the viewpoint of medicine. From a professional standpoint, it allows clinical social workers to demonstrate the importance of integrating the patientâ&#x20AC;&#x2122;s internal and external worlds when understanding the health of the patient. Furthermore, exploring this new role also helps the clinical social worker increase their knowledge of the patientâ&#x20AC;&#x2122;s experience. Many clinical social workers see patients that suffer from chronic pain. The clinical social worker that works on the medical team can contribute to the clinical social work field information about what these patients experience when they are struggling with chronic pain. This provides a gateway to yet another dimension that could provide clinical social workers with a wealth of information to understand our patients. Understanding what nurtures a person, and what depletes them, enables the clinician to understand what brings hope to the patient, and what devastates them. Relationships with family and friends are a source of hope and fulfillment to human beings. A patient with chronic pain may find themselves distant from this essential source of hope and fulfillment, due to relational dynamics. For example, feeling like a burden, or causing burden, can disrupt the process of relating. Helping patients understand the behaviors of others and deal with their own complex emotional reactions can alleviate the sense of powerlessness and abandonment. Understanding the connection between the environment and oneâ&#x20AC;&#x2122;s experience of the self creates the possibility of making a positive impact, of being able to make change occur in the environment, especially between oneself and others. It generates a sense of competence and self-esteem, and helps overcome being helpless and/or overwhelmed.

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While the training makes it beneficial, perhaps even pivotal, for clinical social workers to be part of chronic pain management, many contend that there are not enough clinical social workers offering their expertise in the medical setting. There is a long history of social workers in the medical field as medical social workers, but the resources that clinical social work offers have not been fully utilized. Clinical social workers offer a new, potentially powerful dimension to the changing field of chronic pain management. This movement requires courage and support. This exploratory study encouraged that movement and underscored its importance. Using attachment and relational theories to examine the chronic pain physician-patient dyad, it applied a context that was familiar to clinical social workers, but new to this realm. This study demonstrated that clinical social work skills can add a dimension of understanding for both doctors and patients, and can help improve treatment in an area that can have significant struggles. Studying this particular relationship provided valuable information about how attachment patterns played out in relationships of adulthood- and particularly in medical relationships. It would be interesting to expand this study towards strengthening the quantitative base by administering the ECR-RS and the demographics portion for a larger N. Then, quantitative analyses can be conducted to find trends on dyadic pairings. Perhaps there are tendencies to be found regarding what attachment patterns are evoked from physicians. The findings of this study suggest that this would be a logical, intriguing next step. Implications from this study offer more support towards development of an interdisciplinary chronic pain management team, including the role of the clinical social

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worker. The application of information pertaining to relational dynamics and attachment patterns is the unique ability that the clinical social worker brings to the team. Lastly, this study contributes to the beliefs that clinical social workers upholdthat the human experience is a rich composite of the external and internal, the physical and the mental, the environmental and the social. It offers one more reason to transcend boundaries and to dare to be curious.

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Appendix A

Consent Form

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Individual Consent for Participation in Research INSTITUTE FOR CLINICAL SOCIAL WORK

I,___________________________, acting for myself, Agree to take part in the research entitled: The Impact of Attachment Styles on the Experience of Chronic Pain Treatment. This work will be carried out by Angela Song, LCSW, under the supervision of Barbara Berger, PhD. This work is conducted under the auspices of the Institute for Clinical Social Work; At Robert Morris Center, 401 South State Street, Suite 822, Chicago, IL 60605; (312) 9354232. PURPOSE The purpose of this study is to learn about attachment styles that are found in chronic pain patients and physicians, and determine whether attachment styles impact the treatment of chronic pain. The project involves research with chronic pain patients and physicians who are board certified to treat chronic pain. The results will inform whether attachment styles impact chronic pain treatment, and if they do have in impact, what the impact might be. This knowledge can be used to help improve the delivery of care for chronic pain patients. PROCEDURES USED IN THE STUDY AND THE DURATION You will be asked to take a pencil and paper survey consisting of thirty-six questions. This survey usually takes about ten minutes to complete. After you have completed the survey, you will have a five minute break for water, snacks, and to use the restroom. When you are ready, the researcher will interview you about your experience in the treatment of chronic pain. There are no right or wrong answers at any point of the process. The goal is to get an accurate understanding of your experience. The interview will take about forty minutes to an hour. You are free to share as little or as much as you like. We are grateful for your participation and would like to offer you a $10 gift card to Target or Starbucks. BENEFITS There are no direct benefits to you for your participation. However, the process of discussing oneâ&#x20AC;&#x2122;s experiences is often found to be helpful and therapeutic. Also, your participation helps the field of chronic pain treatment by providing information on how to improve the delivery of care. COSTS There are no expected costs associated with your participation. POSSIBLE RISKS/SIDE EFFECTS

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Sometimes, talking about your experience can cause discomfort and/or emotional distress. The researcher will ask you at various points about how the process feels to you. You can always pause or stop the process at any point. If you are interested, you can be referred to a qualified professional to address your emotional distress. You will also have the researcherâ&#x20AC;&#x2122;s contact information so that they may be contacted later for a referral or for any follow up thoughts that you might want to share. PRIVACY/CONFIDENTIALITY No identifying information will be recorded for the study. The results of the survey and the digital recording will be stored on a password protected device. You have been assigned to a code number, and identifiable data, like your contact information, will be separated from the rest of the research data. Only the researcher will have access to the data. It will not be necessary to use any names or other identifiers when examining the data. After five years, which is the mandatory amount of time needed to keep the data, the flash drive will be erased magnetically. SUBJECT ASSURANCES By signing this consent form, I agree to take part in this study. I have not given up any of my rights or released this institution from responsibility for carelessness. I may cancel my consent and refuse to continue in this study at any time without penalty or loss of benefits. My relationship with the staff of the ICSW will not be affected in any way, now or in the future, if I refuse to take part, or if I begin the study and then withdraw. If I have any questions about the research methods, I can contact Angela Song or Barbara Berger at this phone number (773) 368-0285. If I have any questions about my rights as a research subject, I may contact Dr. John Ridings, Chair of Institutional Review Board; ICSW; At Robert Morris Center, 401 South State Street; Suite 822, Chicago, IL 60605; (312) 935-4232. SIGNATURES I have read this consent form and I agree to take part in this study as it is explained in this consent form.

_________________________________ _____________ Signature of Participant Date

I certify that I have explained the research to ______________ (Name of subject) and believe that they understand and that they have agreed to participate freely. I agree to answer any additional questions when they arise during the research or afterward. ________________________________ _______ Signature of Researcher Date

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Appendix B

Experience of Close Relationships-Relationship Structures (ECR-RS)

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EXPERIENCE OF CLOSE RELATIONSHIPS-RELATIONSHIP STRUCTURES (ECR-RS) This questionnaire is designed to assess the way in which you mentally represent important people in your life. You'll be asked to answer questions about your parents, your romantic partners, and your friends. Please indicate the extent to which you agree or disagree with each statement by circling a number for each item. ------------------------------------------------------------------------------------------------Please answer the following questions about your mother or a mother-like figure ------------------------------------------------------------------------------------------------1. It helps to turn to this person in times of need. strongly disagree 1 2 3 4 5 6 7 strongly agree

2. I usually discuss my problems and concerns with this person. strongly disagree 1 2 3 4 5 6 7 strongly agree

3. I talk things over with this person. strongly disagree 1 2 3 4 5 6 7 strongly agree

4. I find it easy to depend on this person. strongly disagree 1 2 3 4 5 6 7 strongly agree

5. I don't feel comfortable opening up to this person. strongly disagree 1 2 3 4 5 6 7 strongly agree

6. I prefer not to show this person how I feel deep down. strongly disagree 1 2 3 4 5 6 7 strongly agree

7. I often worry that this person doesn't really care for me. strongly disagree 1 2 3 4 5 6 7 strongly agree

8. I'm afraid that this person may abandon me. strongly disagree 1 2 3 4 5 6 7 strongly agree

9. I worry that this person won't care about me as much as I care about him or her. strongly disagree 1 2 3 4 5 6 7 strongly agree

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---------------------------------------------------------------------------------------------Please answer the following questions about your father or a father-like figure ---------------------------------------------------------------------------------------------1. It helps to turn to this person in times of need. strongly disagree 1 2 3 4 5 6 7 strongly agree