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Empathy and Therapeutic RapportMichael W. Adamowicz, LICSW Updated: Oct 5th 2009Once in a while, during a session with a person with substance problems, my mind wanders. I may begin thinking that I've heard this all before. I might get frustrated with the excuses for the slip last week. I might even get to the point of a quick daydream.
At these times, I recall a night long ago to try to help me get back to my therapeutic rapport with the patient.
 When I was 15, I played on my school's soccer team. I had only average skills. Nevertheless, I loved the game.
That year, the school's girl's athletic association invited the boys on sports teams to a roller-skating party. I didn't have a girlfriend at the time. It sucks to be 15 and not have a girlfriend. The roller-skating party seemed like a good chance to try to impress one of the girls.
As the party drew closer, it assumed more and more importance for me. I was pretty good at roller-skating and thought the party was a good place to show off. By the night of the party, I was excited and anxious.
For reasons I no longer remember, my parents were less enthusiastic about me going to the party. I recall a lot of bargaining on my part. They relented and drove me to the roller-skating rink.
By the time I got there, many of the other boys and girls were already skating. I quickly rented a pair of skates, put them on, and headed to the rink. After three steps, I fell backward.
It hurt, a lot. I had never before broken a bone. However, as I lay on the floor I knew with a clear certainty that I had broken my right wrist. Embarrassment and shame competed with pain for first place in my head.
Cautiously but quickly, I got up and headed for the snack bar. It was important that I try to get out of there with as little fanfare as possible. I asked the woman behind the snack bar for ice. She didn't have any. She gave me a cup of soda and suggested that I put that on my arm. The woman did have a phone, though. I called my parents and asked them to pick me up really fast. They were on the way out to a party and were frustrated that they had to cancel their plans.
I removed my skates with my left hand and returned them for my sneakers. I waited for my parents in a corner by the snack bar. My right arm was on the counter, the now warm cup of soda pressed up against my wrist. Just stand here and try not to let anyone notice you, I thought to myself.
Jenny, a long time friend, skated up behind me and playfully hip checked me against the counter. My right arm was pushed into the cash register. What was a barely tolerable, throbbing pain became a shrieking lightning bolt of agony.
Trying to remain cool, I told Jenny that my arm was busted and that she was hurting me. There, my secret was out. Damn. Jenny was good about it. She apologized for hurting me and asked if she could help me.
Just then, my parents arrived. I said good-bye to Jenny and quickly left with my parents. My arm hurt like hell. I wanted to stop somewhere, anywhere and buy ice. My parents thought it would be best to get to the hospital first and get ice there.
In the emergency room, I tried to hold on to my tattered dignity. The nurses and doctors were nice. I tried to be polite and to wait patiently. My arm was eventually x-rayed. Even I could make out the fracture of my right wrist in the x-ray. The doctor said that the fracture needed to be set before putting on a cast.
I never liked getting an injection. Nonetheless, the nurse brought the doctor a tray of syringes and Novocain. My teeth clenched as he injected the anesthetic into several spots around the fracture. The doctor said that it would take a few minutes for the stuff to work. He'd come back in 10 minutes to set the fracture and give me a cast.
My parents were in the exam room with me. We spoke idly until the doctor's return. My pain was lessening but my fear of "setting the bone" grew. I didn't know what that meant. However, I did know that I didn't want anybody to touch my wrist.
The doctor came back. I put on my brave face and said that I was ready. He took my wrist in his hands and squeezed.
The polite and preppy boy on the exam table suddenly became something out of The Exorcist. My parents were strict about swearing. So, of course, behind their backs I had mastered that art. At the top of my voice, I put together the crudest string of words I could muster. If I could have spun my head around 360 degrees and then hurled projectile vomit into the doctor's face, I would have.
The tone in the small room changed dramatically. It seems that doctors don't appreciate being cursed out. He told the nurse to take my parents to the waiting room. I got scared again.
A second nurse unbuckled my belt and pants and told me to roll over. I heard the doctor ask the nurse for Demerol. Great, another shot. This time in the butt. I was grateful that the pain in my arm was now so intense because I did not even notice the next injection.
The doctor and nurse left the exam room and told me they would be back soon.
In what seemed to be a remarkably short time, I started to feel good; very good. There was no pain in my arm. All my anxiety and fear left me. Being in that exam room was quite nice. The colors and lights seemed warm, embracing. I smiled. Who cared if I fell and busted my arm in front of every pretty girl jock in my school? Who needed a girlfriend anyway? I was happy. It was good to have a broken wrist and Demerol coursing through the bloodstream.
By the time the doctor returned, I was high. Flying. The doctor set the bone quickly. The warmth of the ace bandage soaked in plaster was soothing as the doctor wrapped my hand, wrist and forearm. He could have done anything at that point. My hatred of the doctor from a few moments ago now was a warm friendship. Just as long as they kept the Demerol flowing.
I don't remember much about the ride home. I do recall feeling at peace with the world. That night, sleep came easily. The next day, the Demerol was gone and my physical and emotional pains returned.
All these years later, this memory is what I turn to when I begin to lose empathy for any of my patients who have addiction problems. A drug, Demerol in my case, had taken me to a fine and great place. It evaporated all my pains, physical and emotional. The experience was effortless. I knew for the first time that a drug could change every aspect of how I thought and felt. Bliss was only an injection away.
Just as I instantly knew that my arm was broken, I knew immediately after the Demerol that I could be an addict. No matter what else I did in my teens and twenties, I never went close to an opioid.
In my thirties, I severely herniated the disc between C5 and C6. The pain was nauseating. I slept sitting in a chair for six months because I could not tolerate the pain when I lay down. My doctor asked if I wanted something for pain. Due to the intensity of the pain and the length of time before physical therapy was completed, he explained, there was a good chance that I'd become dependent upon a narcotic. He said that over the course of several months, I'd gain tolerance to the drug and he would have to increase the dose to get the same effect. In the end, I'd have to go through withdrawal. I remembered the sweet rapture of Demerol and said no thanks.
Very, very easily, at any point along the way, I could have made a different decision about opioids and me. I just think I was lucky. After the Demerol, I was acutely aware of my vulnerability to the drug. The place that Demerol took me to was seductive and intoxicating. It scared me. It still scares me.
It could be me on the couch in somebody's office talking about my urges and cravings; how the drugs take everything away, even if for only one night. However, I had fear of losing myself in the drugs. And I am just lucky. With any small shift in fate, I could have made an impulsive decision and ultimately wound up in somebody's office, a jail cell or a grave. A number of my friends and some relatives have travelled those other lonely and tragic paths.
These are some of the thoughts help me recover my rapport with the patient and get back into the therapeutic alliance.
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Michael W. Adamowicz, LICSW provides evidence-based psychotherapy to teens, adults, and couples in the Rhode Island and southern Massachusetts areas. Call him at 401-264-0004 to schedule an appointment. View his website here, or read his blog here