Changes in the Therapist

Stephen Kahn, Erika Fromm, Stephen Kahn, Erika Fromm

• Publisher: Routledge
• Year: 2000
• eBook ISBN: 9781135689308
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

Modern therapy has shifted its emphasis to focus on the interpersonal field and on "mutuality of influence." The therapist and the patient are now seen as participating in an ongoing feedback loop, with each influencing the other. This interpersonal focus has brought the therapists and their reactions more into the foreground. Experiences with patients can, in fact, have strong reverberations in practitioners' own lives and can be the cause or source of essential changes in the psyche of the therapist.

This book is the first to explore how efforts to work through issues in therapeutic relationships may permanently affect therapists' beliefs, feelings, and/or actions. The authors, all highly regarded senior clinicians, describe their own reactions and the types of changes that they went through as a consequence of their treatment of a particular patient. They do not make the therapeutic process seem artificially smooth and seamless. In probing their own struggles and difficulties, they illuminate the in-depth workings of the therapeutic relationship. The editors' introduction constructs a systematic framework within which to think about the changes the authors recount. Changes in the Therapist will be of compelling interest to all those involved in therapy.

III
CHANGES IN PERSPECTIVES OF THE SELF

7
Pain: A Story

Brenda Bursch

Lonnie Zeltzer

INTRODUCTION

Jane Watson, a 10-year-old girl, was referred to me (Lonnie Zeltzer) by the chief of pediatric orthopedics because of knee pain. In the orthopedist’s telephone referral, he said, “I have this child crying in my clinic. This is a pain problem…not an orthopedic one. Please help!” Such a direct and personal referral set the stage initially for me to want to relieve this child of her pain, especially when the previous four doctors had not been successful. The assumption I made initially was that this child had neuropathic pain and had just not received the right treatment. We intervened with straightforward approaches to treatment of neuropathic pain, but these were not effective. The distress of this child and her family, including numerous telephone calls for help on a daily basis, eventually led to a hospitalization and a subsequent year of individual hypnotherapy with me for Jane, and family psychotherapy with Brenda Bursch. I present the history and evolution of treatment for the patient, and Dr. Bursch discusses the family treatment. We both explore the feelings and changes that each of us experienced through the process. This was the first patient with whom we worked together. Thus, this story is about not only the development of ourselves as individuals but also the development of our professional relationship.

CASE OVERVIEW

In our first meeting, Jane and her mother, Mrs. Watson, told me their story with strong emotions. The right knee pain began 3 months earlier and had steadily progressed. Jane said that it made her limp until she could no longer walk, and it felt like “something was not right inside.” After an MRI showed torn cartilage Jane underwent surgery to repair the cartilage, with only worsening of the pain after surgery. She described with tears the “torture” that she experienced with physical therapy. Subsequently, a rheumatologist intervened with steroids and knee injections. Mrs. Watson, also teary-eyed, reported that, after no improvement and normal tests, the rheumatologist told Jane, “enough pillows, straighten your legs.... I have other patients with real pain...if you don’t start moving your leg, I’ll put it in a brace and crank it up at night!” This kind of treatment infuriated both Jane and her mother and made them feel even more helpless.

Jane’s family had moved from England 2 years ago because of a job change for Mr. Watson. Her mother was a 40-year-old homemaker who had migraines secondary to stress. Her father, 46-years-old, was an electrical engineer and healthy Jane, the youngest of two children, was in fifth grade. Her 16-year-old brother, a high school senior, was reportedly very angry about the move for the first year but settled down after the parents told him that he could go back to England to live with relatives. Jane was a straight A student and very active in basketball and swimming before the knee pain. All activities, including school attendance, had come to a halt as the knee pain progressed.

After a failed pharmacologic approach during the first week, Jane was seen by Dr. Smith, a psychologist in our pain clinic, for hypnotherapy. He attempted several hypnotic interventions (e.g., direct pain reduction, change of sensation, distraction) but none was effective. His recommendation was that hypnotherapy not be attempted again because Jane was repeatedly disappointed by promises. He further recommended that I work on reducing the pain first; otherwise there would be “serious emotional consequences” if intervention failed again.

At this point, my belief in hypnotherapy, one of the salient routes to treatment, was shaken. I was only a pediatrician, whereas this eminent psychologist, who taught hypnotherapy at national meetings, believed that hypnotherapy should not be used. I began to question myself and my clinical judgement. I had not formally trained in psychotherapy, and the hypnotherapeutic work that I conducted with these children with pain problems was psychotherapy using hypnosis. At this point, I did not even consider the idea that Jane and her mother might have connected to me so strongly that Jane would be resistant to working individually with anyone else (e.g., the psychologist). My shaken belief in my own judgment led me to avoid further discussion of the dynamics of Jane’s behaviors with the psychologist. I felt like the emperor in his “new clothes.” I wanted to reduce her pain so the psychologist could intervene. But, how was I going to reduce her pain if psychotherapy and, in particular, hypnotherapy were not to be used until after Jane’s pain was mitigated?

After numerous telephone calls from both parents pleading for me to do something to take away the pain, I admitted Jane to the hospital the next week. At this point, although I felt that my treatment had failed, I had fantasies that surely my anesthesia colleagues could perform an epidural sympathetic nerve block and “turn off” the sensation and thus the pain. I hoped that a direct biological route to treatment would succeed because the hypnotherapeutic strategy that I initially judged to be the best approach was clearly flawed (or so I believed at that point in time). However, despite enough infused anesthetic to produce a dense motor block, there was no change in Jane’s pain. I assumed that the problem was likely related to the pediatric anesthesiologist’s lack of sufficient technical expertise. I thus asked the senior pain anesthesiologist for help, and he suggested a deeper femoral nerve block.

Following this deeper femoral nerve block, Jane achieved numbness in her leg but no change in her knee pain. Injecting local anesthetic into her knee still produced no change in her pain. The anesthesiologist told me that Jane was “manipulative and faking her pain for attention.” Mrs. and Mr. Watson were becoming increasingly angry with the medical staff and complained to me. They also kept begging me to do something. Jane spent increasing amounts of time crying because of her pain that she reported as being unbearable.

Next, and partly out of desperation, I asked the hospital pediatric psychiatry service and the chief of pediatric orthopedics to evaluate Jane. According to Jane, the child psychiatry fellow seemed to accuse her of faking her pain for attention. Then I asked the fellow’s supervisor, Dr. Bursch, to see this patient and family. Thankfully, Jane and the family reported that they liked Dr. Bursch a lot (perhaps in part because I spoke so highly of her, hoping that she might be the one with the answers). The orthopedist also saw Jane and recommended serial casting of her leg, leaving a window for her knee because it was so sensitive to touch.

The hospitalization extended longer than originally estimated. Because I was due to leave for Paris the next day to attend a conference for 3 weeks, I obtained the details of the procedure and was told that the leg would remain in its bent position and very gradually recasted as an outpatient and straightened. I spent considerable time the evening before leaving reassuring the family and explaining what was going to happen. My guilt at “abandoning” Jane and her family was calmed by the family’s positive response. By this time, I had been giving oral opioids for Jane’s pain as a “temporizing” measure. I left feeling reassured.

In my absence, during the casting procedure, the orthopedist decided to fully straighten Jane’s leg (for which, later, I assumed responsibility and felt very guilty). It was later reported to me by the family that Jane “went berserk” when she awoke. The orthopedist had explained to the family, to no avail, that this had been the best clinical decision because her leg had naturally straightened under anesthesia. This explanation mattered little to the extremely distressed family, and Dr. Bursch spent considerable time with the family as they tried to cope with this crisis.

I received almost daily phone calls in Paris from the first pediatric anesthesiologist to complain about this “needy, impossible” family that he was “only willing to see as an outpatient until I returned.” As if I did not feel guilty enough about abandoning this patient, the idea of leaving this patient in the hands of someone whom I did not trust added to the guilt. Amazing to me now, I even seriously thought about returning earlier than originally planned from Paris in order to assume responsibility of the case. Fortunately, I talked myself out of that idea. However, it is clear to me now that the insecurities about my own skill, knowledge, and clinical judgment, initiated by the recommendation of the pain clinic psychologist that hypnotherapy should not be used until I could reduce the pain, set up a chain reaction of my projections of inadequacy onto the various anesthesiologists and the orthopedist. Furthermore, my guilt about not being able to reduce Jane’s pain was mounting and spreading to guilt about my treating other pediatric patients who had chronic pain. The 1 year of weekly individual therapy with Jane, her family therapy with Dr. Bursch, and the impact of these on ourselves and our relationship are detailed in the following section.

CASE PROGRESSION AND RESOLUTION

Both Jane and her parents struggled with the accuracy of the diagnosis and the relevance of the recommendations to her pain. Issues related to adherence to the treatment plan surfaced frequently. As Mr. and Mrs. Watson became aware of their contribution to Jane’s dependence, their expectations of Jane’s independent functioning increased. During this time, Jane’s extreme emotional distress, cognitive distortions, and regressed self-serving behavior became overt. After learning to express herself more directly and to better modulate her emotion, Jane became significantly more motivated in physical therapy. Finally, with her increased functioning and improved physical health, Jane began to feel a sense of mastery over her environment and body that was not dependent on her ability to manipulate her mother.

The challenges presented by the family to us as the treatment team included the family’s initial strong belief in medical intervention for the treatment of their daughter, their tendency to externalize blame for Jane’s lack of progress, and their inconsistent adherence to behavioral recommendations. We contributed to the difficulty by our desire to please the family, feelings of incompetence, and difficulty sharing responsibility for the case as an interdependent team (i.e., the pre-existing, unresolved trust issues, such as the ones between the pediatric anesthesiologist and me, became magnified, with the help of a family that promoted splitting among the team members). As we learned to refrain from colluding with the family and to share responsibility for the case, our feelings of incompetence lessened, and we found openings for effective intervention as well as growth within ourselves.

After approximately 1 year in physical therapy, hypnotherapy, and family therapy, Jane was able to ambulate without a wheelchair, attend school full-time, and be active in her social and school life. The family psychotherapy focus changed over time from Jane’s knee pain to the emotions and dynamics that were central to the family as a whole. At her 2-year follow-up, Jane was an active adolescent with no residual pain-related disability.

LONNIE ZELTZER’S STORY

Initially, I met with Jane and her parents prior to or just after the family’s psychotherapy sessions with Dr. Bursch. Considering the recommendation from the first psychologist, I avoided hypnotherapy. The individual sessions with Jane that followed and the multiple phone calls from the family focused on the magnitude of Jane’s suffering and the family’s anger at each of us (Dr. Bursch, the anesthesiologist, the orthopedist, and me). Again, I began feeling helpless and reconsulted the senior pain anesthesiologist. I was certain that he would have the answers, and I could absolve my guilt for taking on a patient whom I felt I did not have the skills or experience to treat. He said that a spinal block might be effective but only if Jane really wanted to get better. I found myself angry with him. I wanted him to fix her so that I could feel better.

In the meantime, Dr. Bursch and I changed our approach to encourage Jane to increase function before her pain changed. This was a new strategy that was the opposite of what the pain clinic psychologist had previously recommended. In fact, I was not quite sure that I believed that this newer strategy of increasing function with the pain rather than first reducing the pain was going to work. I was feeling that I was rather cruel to suggest this. However, I told the family that I would give Jane opioids to help her to increase her function but that the parents had to reinforce and maintain the behavioral plan. The behavioral plan was initiated by Dr. Bursch. Although the behavioral plan made sense to me cognitively, my guilt for not being able to improve Jane’s pain made it difficult for me to hear about Jane’s suffering and to have emotional faith in the plan.

The parents would call Dr. Bursch and me, complaining about the other or indicating differing opinions that we were telling the family. Because of this behavior, Dr. Bursch and I agreed to call each other as soon as we received a call from the Watsons so that splitting would be minimized and we could help together to contain the family’s anxiety. I was glad for the ongoing support from Dr. Bursch so that I could receive reassurance because I continued to feel inadequate to treat this patient. To add to my guilt, Mr. Watson kept asking if there was anything else we could do or somewhere else in the country where there was more experience and where they could go to get help for Jane. We told the family that the senior pain anesthesiologist who had already seen Jane was one of the national experts on neuropathic pain. In truth, I was still feeling angry with this anesthesiologist for not fixing her pain. He met with the family and recommended that spinal anesthesia was a possibility but only when Jane was ready and really wanted to undergo that treatment. However, he did not believe she was currently ready.

Following this meeting, I received a long letter from Mr. Watson (with copies to Dr. Bursch and to all physicians who had ever been involved in Jane’s care), in which he outlined all of the failed treatments and disappointments especially when Jane was “lied to” with the casting and leg straightening. He indicated that I had no plan until we met with the senior anesthesiologist, who was expected to do something. However, he was shocked that the anesthesiologist said that Jane was not ready. I felt overwhelmingly guilty especially when he accused me of forcing Jane to experience incredible pain. I felt I was an imposter. I am not an anesthesiologist, I do not perform nerve blocks. Why did I think that I knew how to treat children with pain? I was believing that I had done a terrible disservice to this family. My confidence in myself was at its lowest point. I found myself dreaming of this patient and her family with disasters befalling Jane, and I would be a helpless bystander. Jane occupied my thoughts when I was awake as well.

My helpless feelings in relation to Jane entered my own psychotherapy sessions. I found childhood feelings of helplessness connected to my inabilities to get my father to stop gambling or to help my mother to do so. My own academic successes had worked at various times to divert my parents’ attention from their own problems, but clearly beneath these accomplishments I felt inadequate. Here was this feeling emerging so strongly again.

I needed reassurance and my first reaction was to call Dr. Bursch for emotional support under the guise of needing to develop a plan for how to handle the letter. Somehow, through discussions with each other about our own worries and about feelings of inadequacy, we were each able to encourage each other’s belief in our own basic clinical intuitions. We talked about other patients whom we had each treated, we talked about ourselves, and, through this process, we found mutual support for working together with this family. I decided at this point that my clinical judgment in this matter was sound and that I would pursue my initial instincts about the value of hypnotherapy. I also decided that I would no longer need to look to the anesthesiologist for magic. Dr. Bursch and I met with the family to deal with their concerns and to state clearly and resolutely our therapeutic plans. It appeared as if when we began to trust ourselves and each other, the family dysfunction was contained, and Jane began to make progress. Conversely, as the family began to trust us, we began to trust ourselves and to use each other for ongoing support for our own judgments.

Jane’s relationship with me was good from the start, despite the father’s letter about loss of trust. Our sessions would typically begin with Jane telling me about her frustrations at home, in school, with friends, at the doctors, and, almost always, in family therapy sessions with Dr. Bursch whom she “despised.” She would complain bitterly about how Dr. Bursch did not understand her (i.e., like I did) and how Dr. Bursch enjoyed making her suffer. There were times that Jane’s complaints created worry about whether Dr. Bursch was doing the right thing in family therapy. However, I was feeling comfortable enough in my relationship with Dr. Bursch that I was able to discuss these worries with her and to feel reassured through these discussions. Soon, Jane’s complaints about Dr. Bursch no longer bothered me. In fact, these complaints reassured me that the family therapy was going well. After all, when I first met Jane, she never became or admitted to being angry or distressed about anything.

If my hypnotherapy sessions with Jane had taken place earlier during the course of treatment, when my guilt was high and my confidence and collegial trust low, I easily could have inadvertently colluded with the splitting that Jane was attempting. Instead, I was able to listen to Jane, ask her a few questions and then suggest that she had suffered long enough and worked so hard that she could now enjoy a deep state of relaxation and comfort. After an induction I suggested that she could go to a place where she knew how to feel good, strong, in control, cared for, and happy. Eventually, this became a place where she could run, swim, and do all the things physically that she could not do because of her knee pain. She reported exercising vigorously during the hypnotherapy and that it felt good. However, she always saw her knee as just a knee but not hers. Whenever I suggested a central sensory control station in her brain that controlled the nerve signals for sensory information coming from her body to her brain, she was able to achieve deep anesthetic experiences with all parts of her body except her right knee. Throughout the year, she was unable in her imagination to picture herself touching or bending her knee. Clinically, Jane reported the same amount of pain but that she was able to cope with it better. Her functioning dramatically improved as did her abilities to ex-press anger and to act more independently. Simultaneously, progress was being made in family therapy.

I was feeling increasingly competent; I felt increasing admiration for Dr. Bursch in her clinical skills, judgment, and perseverance with this difficult family. Over time, I felt the same about myself. I also realized how much I had learned from working with Dr. Bursch. I had not previously had an integrated working relationship with the other mental health professionals I knew. The traditional model had been my medical visits and their psychotherapy sessions, as in parallel play. However, with Dr. Bursch, I felt as if we were cotherapists, each with our own role, but working jointly in one coordinated effort. I found that I looked forward to our discussions about each of our sessions with this child and her family afterward. I think that these discussions with Dr. Bursch helped me to feel that I had good clinical skills and judgment. I even began to be amazed, on occasion, at the metaphors that seemed to emerge by themselves during my hypnotherapy sessions with Jane that seemed to be pertinent to her progress.

In summary, my personal experiences with the Watsons and with Dr. Bursch have helped me to trust myself and to feel good about my clinical judgment and skills as a hypnotherapist for children with pain. Additionally, Dr. Bursch and I have developed an ongoing, mutually beneficial and enjoyable professional relationship. Because of the changes we experien...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Foreword
• Introduction
• I Changes in Attitude About Death
• II Changes in Ability to Mourn Parents
• III Changes in Perspectives of the Self
• IV Changes in Technique
• V Changes in Tolerance for Uncertainty
• About the Contributors