Monthly Archives: April 2014

Injections and the Personal Touch

“Fear of the needle is usually acquired in childhood.  The psychic trauma to millions of the population produced in this way undoubtedly creates obstacles to good doctor-patient relationships, essential diagnostic procedures, and even life-saving therapy.”  Janet Travell, “Factors Affecting Pain of Injection” (1955)[1]

It was during the 1950s that the administration of hypodermic injections became a fraught enterprise and a topic of medical discussion.  With World War II over and American psychoanalysis suffusing postwar culture, including the cultures of medicine and psychiatry, it is unsurprising that physicians should look with new eyes at needle penetration and the fears it provoked.

In the nineteenth century, it had been all about pain relieved, sometimes miraculously, by injection of opioids.  Alongside the pain relieved, the pain of the injection was quite tolerable, even minor, a mere afterthought.  But in the mid-twentieth century pain per se took a back seat.  It was no longer about the painful condition that prompted injection.  Nor, really, was it about the pain of injection per se.  Psychodynamic thinking trumped both kinds of pain.  Increasingly, the issue before physicians, especially pediatricians, was about two things:  the anxiety attendant to injection pain and the lasting psychological damage that was all too often the legacy of needle pain.  Elimination of injection pain mattered, certainly, but it became the means to a psychological end.  Relieve the pain, they reasoned, and you eliminate the apprehension that exacerbates the pain and leaves deep psychic scars.

And so physicians were put on notice.  They were enjoined to experiment with numbing agents, coolant sprays, and various counterirritants to minimize the pain that children (and a good many adults) dreaded.  They were urged to keep their needles sharp and their patients’ skin surfaces dry.  Coolant sprays and antiseptic solutions that left a wet film, after all, could be carried into the skin as irritants.  For the muscular pain attendant to deeper injections, still stronger anesthetics, such as procaine, might be called for.  Physicians were also encouraged to reduce injection pain through new technologies, to use, for example, hyposprays and spring-loaded presto injectors.  Injection “technique” was a topic of discussion, especially for intramuscular injections of new wonder drugs such as streptomycin.  To be sure, new technologies and refined technique often failed to eliminate injection pain, especially when a large volume of solution was injected.  But, then again, pain relief was only a secondary goal. The point of the recommendations was primarily psychological, viz., to eliminate “the psychological reaction to piercing the skin.”[2]  It was anticipation of pain and the fear it engendered that jeopardized the doctor-patient relationship.

Psychoanalysts themselves, far removed from the everyday concerns of pediatricians, family physicians, and internists, had little to say on the topic.  They were content to call attention now and again to needle symbolism – invariably phallic in nature – in dreams and childhood memories.  In 1954, the child analyst Selma Fraiberg recalled “The theory of a two-and-a-half-year-old girl who developed a serious neurosis following an observation of coitus.  The child maintained that ‘the man made the hole,’ that the penis was forcibly thrust into the woman’s body like the hypodermic needle which had been thrust into her by the doctor when she was ill.”   Pity this two and a half year old.

Inferences about male sadism and castration anxiety were integral to this train of thought.  In 50s-era psychoanalysis, needle injection could symbolize not only “painful penetration,” but also the sadistic mutilation of a little girl by a male doctor.[3]  One wants to say that such strained psychoanalytic renderings are long dead and buried, but the fact is they still find their way into the literature from time to time, usually in the context of dream interpretations.  Here is one from 1994:

Recently Ms. K mentioned a dream in which she was diabetic and had little packets of desiccated insulin which were also like condoms.  All she needed now was a hypodermic syringe and a needle.  I pointed out the sexual nature of the dream with its theme of penetration; she then remembered that in the dream a woman friend had lifted her skirt and Ms. K had ‘whammed the needle right in’.[4]

Psychoanalytic interpretive priorities change over time, whether or not in therapeutically helpful ways being a perennial subject of debate.  By the 1990s, there was belated recognition that children’s needle phobias really didn’t call for analytic unraveling; they derived from the simple developmental fact that “children are exposed to hypodermic needles prior to their ability to understand what is going on,” and, as such, were more amenable to behavioral intervention than psychoanalytic treatment.  In the hospital setting, in particular, children needed simple strategies to reduce fear, not psychoanalytic interpretations.[5]

In 1950s medicine, psychoanalysis was at its best when its influence was subtle and indirect.  Samuel Sterns’s thoughtful consideration of the “emotional aspects” of treating patients with diabetes, published in the New England Journal of Medicine in 1953, is one such example.  Sterns worked out of the Abraham Rudy Diabetic Clinic of Boston’s Beth Israel Hospital, and he expressed indebtedness to the psychiatrist-psychoanalyst Grete Bibring and other members of her department for “many discussions” on the topic.

For most diabetics, of course, daily injections, self-administered whenever possible, were an absolute necessity.  And resistance to the injections, then as now, undercut treatment and resulted in poor glycemic control.[6]  How then to cope with the diabetic’s resistance to the needle, especially when “the injection of insulin is sometimes associated with a degree of anxiety, revulsion or fear that cannot be explained by the slight amount of pain involved.”[7]

Psychoanalysis provided a framework for overcoming the resistance.  It was not a matter of “simple reassurance” about insulin injections, Sterns observed, but – and it is Bibring’s voice we hear –

Recognition that apparently trivial and unfounded complaints about insulin injections may be based on deeply rooted anxiety for which the patient finds superficial rationalizations enables the physician to be more realistic and tolerant, and more successful in dealing with the problem.

Realism, tolerance, acceptance – this was the psychoanalytic path to overcoming the problem.  Physicians had to accept that diabetics’ anxiety about injections arose from “individual personalities,” and that each diabetic had his or her own adaptively necessary defenses.  Exhortation, criticism, direct confrontation – these responses had to be jettisoned on behalf of the kindness and understanding that would lead to a “positive interpersonal relation.”  This entailed an understanding of the patient’s transference to the physician:

It is particularly apparent that most of the reactions of juvenile diabetic patients to discipline, authoritativeness or criticism by the physician are really identical with their reactions to similar situations involving their parents.

And it included a  like-minded willingness to wrestle with the countertransference as an obstacle to treatment:

Even the occasional display of an untherapeutic attitude by the physician is enough to interfere with the development of a relation that will enable him to obtain maximal cooperation from the patient.  If the physician cultivates awareness of his own reactions to a difficult patient, he will be less easily drawn into retaliation or other negative behavior.[8]

The point of the analytic approach was to lay the groundwork for a “positive interpersonal relation” that would enlist the patient’s cooperation, and “not through anxiety or fear of the disease or the physician, but rather through the wish to be well and to gain the physician’s approval.”[9]  Sympathetic acceptance of the patient’s fears, of the defenses against those fears, of the life circumstances that led to the defenses – this was the ticket to the kind of positive transference relationship that the physician could use to his and the patient’s advantage.

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Sterns’s paper of 1953 remains helpful to this day; it exemplifies the application of general psychoanalytic concepts to real-world medical problems that, as I suggested in the final chapter of Psychoanalysis at the Margins (2009), may breathe new life into a beleaguered profession.  The reasonableness of Sterns’s recommendations stands in contrast to the insular irrelevance of  George Moran’s “Psychoanalytic Treatment of Diabetic Children” (1984), where poor glycemic control among children becomes a “metaphorical expression[s] of psychological disturbance” — framed in terms of “entrenched defensive structures” and “drive derivatives” – that calls for psychoanalytic treatment, sometimes via “prolonged stays” of up to several months in pediatric wards.[10]  And yet, there is something missing from Sterns’s commentary.  Like other writers of his time, he was concerned lest needle anxiety become an obstacle to a good doctor-patient relationship.  Cultivate the relationship through sympathetic insight into the problem, he reasoned, and  the obstacle would diminish, perhaps even disappear.  What he ignored – indeed, what all these hospital- and clinic-based writers of the time ignored – is the manner in which a preexisting “good doctor-patient relationship” can defuse needle anxiety in the first place.

Nineteen fifty three, the year Sterns’s paper was published, was also the year my father, William Stepansky, opened his general practice at 16 East First Avenue, Trappe, Pennsylvania.  My father, as I have written, was a Compleat Physician in whom wide-ranging procedural competence commingled with a psychiatric temperament and deeply caring sensibility.  In the world of 1950s general practice, his office was, as Winnicott would say, a holding environment.  His patients loved him and relied on him to provide care.  If injections were part of the care, then ipso facto, they were caring interventions, whatever the momentary discomfort they entailed.

The forty years of my father’s practice spanned the first 40 years of my life, and, from the time I was around 13, we engaged in ongoing conversations about his patients and work.  Never do I recall his remarking on a case of needle anxiety, which is not to deny that any number of patients, child and adult, became anxious when injection time arrived.  My point is that he contained and managed their anxiety so that it never became clinically significant or worthy of mention.  At the opposite end of the spectrum, I know of elderly patients who welcomed him into their homes several times a week for injections – sometimes just vitamin B-12 shots – that amplified the human support he provided.

Before administering an injection, my father firmly but gently grasped the underside of the patient’s upper arm, and the patient felt held, often in just those ways in which he or she needed holding.  When one’s personal physician gives an injection, it may become, in some manner and to some extent, a personal injection.  And personal injections never hurt as much as injections impersonally given.  This simple truth gets lost in the contemporary literature that treats needle phobia as a psychiatric condition in need of focal treatment.   A primary care physician remarked to me recently that she relieved a patient’s severe anxiety about getting an injection simply by putting the injection on hold and sitting down and talking to the patient for five minutes.  In effect, she reframed the meaning of the injection by absorbing it into a newly established human connection. Would that all our doctors would sit down with us for five minutes and talk to us as friendly human beings, as fellow sufferers, before getting down to procedural business.

I myself am more fortunate than most.  For me the very anticipation of an injection has a positive valence.  It conjures up the sights and smells and tactile sensations of my father’s treatment room.  Now in my 60s, I still have in my nostrils the bracing scent of the alcohol he used to clean the injection site, and I still feel the firm, paternal grasp of his hand on my arm at the point of injection.  I once remarked to a physician that she could never administer an injection that would bother me,  because at the moment of penetration, her hand became my father’s.

Psychoanalysts who adopt the perspective of object relations theory speak of “transitional objects,” those special inanimate things that, especially in early life, stand in for our parents and help calm us in their absence.  Such objects become vested with soothing human properties; this is what imparts their “transitional” status.  In a paper of 2002, the analyst Julie Miller ventured the improbable view, based on a single case, that the needle of the heroin addict represents a “transitional object” that fosters a maternal connection the addict never experienced in early life.[11]  For me, I suppose, the needle is also a transitional object, albeit one that intersects with actual lived experience of a far more inspiriting nature.  To wit, when I receive an injection it is always with my father’s hand, life-affirming and healing.  It is the needle that attests to a paternal connection realized, in early life and in life thereafter.  It is an injection that stirs loving memories of my father’s medicine.   So how much can it hurt?

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[1] J. Travell, “Factors affecting pain of injection,” JAMA, 58:368-371, 1955, at p. 368.

[2] J. Travell, “Factors affecting pain of injection,” op. cit.; L. C. Miller, “Control of pain of injection,” Bull Parenteral Drug A., 7:9-13,1953; E. P. MacKenzie, “Painless injections in pediatric practice,” J. Pediatr., 44:421, 1954; O. F. Thomas & G. Penrhyn Jones, “A note on injection pain with streptomycin,” Tubercle, 36:157-59, 1955; F. H. J. Figge & V. M. Gelhaus, “A new injector designed to minimize pain and apprehension of parenteral therapy,” JAMA, 160:1308-10, 1956.  There were also needle innovations in the realm of intravenous therapy, e.g., L. I. Gardner & J. T. Murphy, “New needle for pediatric scalp vein infusions,” Amer. J. Dis. Child., 80:303-04, 1950.

[3] S. Fraiberg, “A critical neurosis in a two-and-a-half-year girl,” Psychoanal. Study Child, 7:173-215, 1952, at p. 180; S. Fraiberg, “Tales of the discovery of the secret treasure,” Psychoanal. Study Child, 9:218-41, 1954, at p. 236.

[4] I. D. Buckingham, “The effect of hysterectomy on the subjective experience of orgasm,” J. Clin. Psychoanal., 3:607-12, 1994.

[5] D. Weston, “Response,” Int. J. Psychoanal., 78:1218-19, 1997, at p. 1219; C. Troupp, “Clinical commentary,” J. Child Psychother., 36:179-82, 2010.

[6] There is ample documentation of needle anxiety among present-day diabetics, e.g., A. Zambanini, et al., “Injection related anxiety in insulin-treated diabetes,” Diabetes Res. Clin. Prac., 46:239-46, 1999 and A. B. Hauber, et al., “Risking health to avoid injections: preferences of Canadians with type 2 diabetes,” Diabetes Care, 28:2243-45, 2005.

[7]S. Stearns, “Some emotional aspects of the treatment of diabetes mellitus and the role of the physician,” NEJM, 249:471-76, 1953, at p. 473.

[8] Ibid., p. 474.

[9] Ibid.

[10]P. E. Stepansky, Psychoanalysis at the Margins (NY: Other Press, 2009), pp. 287-313; G. S. Moran, “Psychoanalytic treatment of diabetic children,” Psychoanal. Study Child, 39:407-447, at pp. 413, 440. 

[11]J. Miller, “Heroin addiction: the needle as transitional object,” J. Amer. Acad. Psychoanal., 30:293-304, 20.

Copyright © 2014 by Paul E. Stepansky.  All rights reserved.