USING CTr EMPIRICALLY

1. USING CTr EMPIRICALLY CTR evolution of understanding CTR elements Westen article and its implications Illustrations :1 strongarm 2

2. “The prevailing medical paradigm has no capacity to incorporate the concept that a relationship is a physiologic process as real and as potent as any pill or surgical procedure” • W B Strean Commentary CFP 2009; 55 :965-7

3. CONTEXT OF COUNTERTRANSFERENCE HX QUOTE RE RELATIONSHIP EMOTIONAL TRANSFER MIRROR NEURONS EMPATHY MENTALIZATION

4. CTr Context cont’d • humans are exquisitely sensitive to others moods…below the radar…understanding mood is a mentalising process • we are responsible for our emotional reactions to patients • we are trained to ignore or mistrust those reactions

5. EMOTIONAL CONTAGION • In the March 2005 issue of The Journal of Applied Psychology, Saavedra and colleague Thomas Sy at California State University at Long Beach examined the effects of a leader’s mood on a group. • Result: The leaders’ moods ruled, and negative moods ruled most. If a leader was up, some team members’ moods also rose. But if he or she was down, everyone was down.

7. strong reactions by md • 1949 ‘HATE IN THE COUNTERTRANSFERENCE’WINNICOTT • 1978 ‘THE HATEFUL PATIENT’ GROVES CLINGERS, DEMANDERS, HELP-REJECTERS, SELF-DESTRUCTIVE DENIERS • 1995 PHYSICIANS’ EMOTIONAL REACTIONS TO PATIENTS RECOGNISING AND MANAGING COUNTERTRANSFERENCE ; A.A. MARSHALL, R. C. SMITH • 2001 USING ATTTACHMENT THEORY HUNTER, MAUNDER

8. ARTICLE • COUNTERTRANSFERENCE PHENOMENA AND PERSONALITY PATHOLOGY IN CLINICAL PRACTICE: AN EMPIRICAL INVESTIGATION • AM J PSYCHIATRY 2005; 162: 890-898 • BETAN/HEIM/CONKLIN/WESTEN

9. the article addresses Professional CTr not personal • it addresses specific qualities not just positive or negative

10. Aims • develop a specific measure of CTr reactions • compare CTr factors with clinical variables • specifically ascertain any CTr factor correlation with narcissistic PD • assess the use of CTr response as a transtheoretical diagnostic tool

11. Method • random 181 clinicians • random choice of patient • standardised patient demographic • use of CTr Questionnaire • use of DSM IV • Q-sort and Factor Analysis • partial correlation analysis of Factors with Cluster symptoms

12. CTr Questionnaire

13. Factor Analysis

14. Mapping of CTr Factors with Cluster B pathology

15. Implications • specific disturbances elicit CTr responses in a typical pattern • clinical awareness of such patterns can help define clinical pathology • clinical awareness of CTr experience can facilitate optimal responsiveness by offsetting feelings of persecution by MD

17. WHY BOTHER • RISK MANAGEMENT • SIGNIFICANT % OF PATIENT POPULATION • PROFESSIONAL DEVELOPMENT

18. DUCK • 2005 : 73000 NURSES ATTACKED ie 30% OF HOSPITAL NURSES AND 50% OF LONG TERM CARE • HEALTH CARE RISK OF INJURY UP TO 12 TIMES MORE THAN ANY OTHER INDUSTRY

19. DOCTOR’S EXPERIENCE • NEGOTIATION IMPOSSIBLE • NO REDEEMING QUALITIES SEEN IN PATIENT • DREAD PATIENT’S VISIT, FEEL OVERWHELMED • RESCUE URGENCY • OFFERS TOO MUCH OR TOO LITTLE

20. Literature Review n = 500 outpatients -- 15% rated as difficult Mental disorder (incl. sub. use ) > 5 somatic symptoms Severe symptoms Poorer functioning High Dissatisfaction High Utilisation Hahn, Kroenke,J. of Gen Int Med 1996 Jackson,Kroenke, Archives Int Med 1999

21. Literature Review n = 500 outpatients -- 15% rated as difficult Mental disorder (incl. sub. use ) > 5 somatic symptoms Severe symptoms Poorer functioning High Dissatisfaction High Utilisation Hahn, Kroenke,J. of Gen Int Med 1996 Jackson,Kroenke, Archives Int Med 1999

22. MD-rated difficulty • Difficulty increases with increasing score on personality disorder criteria • Difficulty increases markedly with : More than 1 of somatization, personality disorder, psychiatric disorders (Hahn, 1994)

23. ASYMMETRY OF POWER Psychiatric Model POV : ‘Black Box’ Relational Model POV

24. DIFFICULT PATIENT RELATIONSHIP A POWER STRUGGLE: COMPROMISED WORKING RELATIONSHIP

25. CONTRACTUAL UNDERSTANDING PATIENT-DOCTOR RIGHTS RESPONSIBILITIES ROLES

26. PET PSYCHIATRIST……..

27. DR URSUS’ PATIENT

28. DR URSUS’ PATIENT ISSUES • BOUNDARIES • Dr’s Reactions • POWER STRUGGLE • PSYCHOLOGY

29. DISORGANISED PATIENTCLINICAL PHENOMENA • LOW REFLECTIVE FUNCTION • BOUNDARY TRANSGRESSIONS • EMOTIONALLY CHAOTIC • CHRONIC SUICIDALITY • DISSOCIATION

31. The Matrix Reloaded Show your face you are the mirror itself

32. The Healthy Matrix SUSTAINING RELATIONSHIP ABILITY TO SELF-SOOTH REFLECTIVE CAPACITY PLEASURE CAPACITY EMPATHIC CAPACITY TRUST CAPACITY

33. Failures in the Matrix • Caregiver UNAVAILABLE INTRUSIVE • INCONSISTENT UNRESPONSIVE • POOR FIT care-giver/child • ABUSE TRAUMA • DEFICIT of MENTALISATION • ATTACHMENT INSECURITY

34. ATTACHMENT STYLES • SECURE • INSECURE ANXIOUS AVOIDANT FEARFUL DISORGANIZED • AFFECT EXPRESSION MODULATION • COHERENCE • REFLECTIVE ABILITY •IMPLICATIONS FOR MANAGEMENT

35. PRIMITIVE COPING MECHANISMS • Black/White Feeling States • PROJECTION • ENACTMENTS

37. GOOD WILL HUNTING GOING FOR THE THROAT JUST WON’T DO Direct Emotional Transfer

38. Direct Emotional Transfer NEUROPHYSIOLOGY: MIRROR NEURONS PSYCHOANALYSIS: PROJECTIVE IDENTIFICATION SOCIAL PSYCHOLOGY: EMOTIONAL CONTAGION

39. Emotional Transfer ･Neumann R, Strack F. participants who expected to be tested for text comprehension listened to an affectively content-neutral speech spoken in a sad or happy voice. …the emotional expression induced a congruent mood state in the listeners. J Pers Soc Psychol. 2000 Aug;79(2):211-23.

40. Stephen Jay Gould variation itself is nature’s only irreducible essence

41. BE A GENIUS

44. MIRROR NEURONS • At London’s University College, psychologist Tonia Singer used brain scans to explore empathy in 19 romantic couples. The experiment was simple. Both individuals were hooked to brain scans. One was given a slight electric shock while the other watched. Scans showed identical brain reactions. One partner was shocked, but the other partner’s pain center lighted up as if he or she had also been jolted.