USING CTr EMPIRICALLY

USING CTr EMPIRICALLY

CTR evolution of understanding

CTR elements

Westen article and its implications

Illustrations :1 strongarm 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

CONTEXT OF COUNTERTRANSFERENCE

HX

QUOTE RE RELATIONSHIP

EMOTIONAL TRANSFER

MIRROR NEURONS

EMPATHY

MENTALIZATION

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

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.

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

ARTICLE

COUNTERTRANSFERENCE PHENOMENA AND PERSONALITY PATHOLOGY IN CLINICAL PRACTICE: AN EMPIRICAL INVESTIGATION

AM J PSYCHIATRY 2005; 162: 890-898

BETAN/HEIM/CONKLIN/WESTEN

the article addresses Professional CTr not personal

it addresses specific qualities not just positive or negative

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

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

CTr Questionnaire

Factor Analysis

Mapping of CTr Factors with Cluster B pathology

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

WHY BOTHER

• RISK MANAGEMENT

• SIGNIFICANT % OF

PATIENT POPULATION

• PROFESSIONAL

DEVELOPMENT

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

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

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

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

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)

ASYMMETRY OF POWER

Psychiatric Model POV :

‘Black Box’

Relational Model POV

DIFFICULT PATIENT RELATIONSHIP

A POWER STRUGGLE:

COMPROMISED WORKING RELATIONSHIP

CONTRACTUAL UNDERSTANDING

PATIENT-DOCTOR

RIGHTS RESPONSIBILITIES ROLES

PET PSYCHIATRIST……..

DR URSUS’ PATIENT

DR URSUS’ PATIENT ISSUES

• BOUNDARIES

• Dr’s Reactions

• POWER STRUGGLE

• PSYCHOLOGY

DISORGANISED PATIENTCLINICAL PHENOMENA

• LOW REFLECTIVE FUNCTION

• BOUNDARY

TRANSGRESSIONS

• EMOTIONALLY CHAOTIC

• CHRONIC SUICIDALITY

• DISSOCIATION

The Matrix Reloaded

Show your face you are the mirror itself

The Healthy Matrix

SUSTAINING RELATIONSHIP

ABILITY TO SELF-SOOTH

REFLECTIVE CAPACITY

PLEASURE CAPACITY

EMPATHIC CAPACITY

TRUST CAPACITY

Failures in the Matrix

• Caregiver UNAVAILABLE INTRUSIVE

• INCONSISTENT UNRESPONSIVE

• POOR FIT care-giver/child

• ABUSE TRAUMA

• DEFICIT of MENTALISATION

• ATTACHMENT INSECURITY

ATTACHMENT STYLES

• SECURE

• INSECURE

ANXIOUS

AVOIDANT

FEARFUL

DISORGANIZED

• AFFECT EXPRESSION MODULATION

• COHERENCE

• REFLECTIVE ABILITY

•IMPLICATIONS FOR MANAGEMENT

PRIMITIVE COPING MECHANISMS

• Black/White Feeling States

• PROJECTION

• ENACTMENTS

GOOD WILL HUNTING

GOING FOR THE THROAT JUST WON’T DO

Direct Emotional Transfer

Direct Emotional Transfer

NEUROPHYSIOLOGY:

MIRROR NEURONS

PSYCHOANALYSIS: PROJECTIVE IDENTIFICATION

SOCIAL PSYCHOLOGY: EMOTIONAL CONTAGION

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.

Stephen Jay Gould

variation itself is nature’s only irreducible essence

BE A GENIUS

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.