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USING CTr EMPIRICALLY

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

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USING CTr EMPIRICALLY

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  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.

  6. 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

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

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

  9. 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

  10. 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

  11. CTr Questionnaire

  12. Factor Analysis

  13. Mapping of CTr Factors with Cluster B pathology

  14. 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

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

  16. 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

  17. 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

  18. 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

  19. 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

  20. 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)

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

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

  23. CONTRACTUAL UNDERSTANDING PATIENT-DOCTOR RIGHTS RESPONSIBILITIES ROLES

  24. PET PSYCHIATRIST……..

  25. DR URSUS’ PATIENT

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

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

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

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

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

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

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

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

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

  35. 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.

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

  37. BE A GENIUS

  38. 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.

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