LAS VEGAS—Despite increased patient loads and less time for office visits, it is critical for providers to remain aware of the “unique individuals with unique injuries and problems” who present with chronic pain, said Anthony A. Whitney, MS, LMHC, BCB, a behavioral therapist and licensed mental health counselor at St. Luke’s Rehabilitation Institute in Spokane, Washington.

“Coping skills, negative and positive experiences, environment, type of injury, and genetics are just a few factors that contribute to an individual’s response/adjustment” to chronic pain, he said.

At PAINWeek 2014, Whitney identified and reviewed behavioral profiles common in patients struggling with chronic pain. He also provided tactics for working with and avoiding potential pitfalls associated with these profiles, including “ten useful coping skills for providers” (see Table).

Table. 10 Useful Coping Skills for Providers

 Allow patients to vent their feelings
 Strengthen your communication skills
 Become a more effective history taker
 Try not to judge
 Remain calm and confident
 Understand your own strengths and vulnerabilities
 Be patient
 Be proactive
 Avoid becoming an enabler
 Respect your patients

In his clinical experience, patients may present with chronic pain associated with sexual trauma or childhood abuse. Many are dissatisfied with their jobs, have unresolved anger, point to unfair circumstances or wrong doing, and are waiting to be “fixed.” Others have feelings of betrayal and are needing or seeking “justice.”

“One of the more important and influential tools a provider needs to help/ cope with maladaptive behavioral profiles is the handling of the transference,”Whitney said, which, in the words of Freud, “may in practice amount to an arduous task for the patient and a trial of patience” for the provider.

The clinician may encounter patients with specific maladaptive behavioral profiles such as the “manipulator,” the “borderline personality,” the “attention seeker,” the “self-lover,” the “hard worker,” and the “devoted.”

To help providers cope with a specific maladaptive behavioral profile, Whitney first provided an overview of aspects of that individual behavior, then how to avoid pitfalls. For example, a patient with an “attention seeker” profile will seek, create and manipulate attention, is hyperaware of pain and can be seductive, has difficulty focusing and may be forgetful or confused, have little to no body awareness, and present as a “victim,” demanding and acting out. That patient’s “repetition compulsion” is that “you will not listen; you will not believe what they say is true,” said Whitney.

To avoid pitfalls of the “attention seeker,” he advised providers to:

    • Give the patient an outlet for expressing themselves; if time is limited, let them write you a letter, email, voicemail
    • Keep the patient in the moment, help them focus on the problem at hand
    • Increase their awareness of actions and gains
    • Use tracking tools (journal, symptoms list, others)
    • Set limits in a nonjudgmental way
    • Be patient until you build rapport
    • Use handouts and written instruction
    • Make reactions neutral, drama detached and earnest

“A good provider/patient relationship is essential for a successful outcome,” Whitney concluded.