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

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Presentation on theme: "USING CTr EMPIRICALLY CTR evolution of understanding CTR elements Westen article and its implications Illustrations :1 strongarm 2."— Presentation transcript:

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.

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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:  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

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

18 DUCK 2005 : 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 MD-rated difficulty Discordance between MD and patient  Explanation of illness  Aims of care Patient distress, dissatisfaction  Only mildly dissatisfied with care compared to non-difficult patients but feel that “the doctor will eventually be able to help if I keep attending” Chronic attendance (Sharpe, 1994)

24 CONSTRAINTS SHARING BENIFICENCE COMPASSION TRUST POWER IN RELATIONSHIP

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

26 INFORMED CONSENT RIGHT TO HIRE/FIRE ADVOCATES OMBUDSMAN CPSO PATIENT POWER

27 DR POWER ETHICAL CODES MAINTAIN FRAME REFLECTIVE SELF MONITOR

28 DIFFICULT PATIENT RELATIONSHIP A POWER STRUGGLE: COMPROMISED WORKING RELATIONSHIP

29 CONTRACTUAL UNDERSTANDING PATIENT-DOCTOR RIGHTS RESPONSIBILITIES ROLES

30 PET PSYCHIATRIST……..

31 DR URSUS’ PATIENT

32 DR URSUS’ PATIENT ISSUES BOUNDARIES Dr’s Reactions POWER STRUGGLE PSYCHOLOGY

33 DISORGANISED PATIENT CLINICAL PHENOMENA LOW REFLECTIVE FUNCTION BOUNDARY TRANSGRESSIONS EMOTIONALLY CHAOTIC CHRONIC SUICIDALITY DISSOCIATION

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35 The Matrix Reloaded Show your face you are the mirror itself

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

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

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

39 PRIMITIVE COPING MECHANISMS Black/White Feeling States PROJECTION ENACTMENTS

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

42 NEUROPHYSIOLOGY: MIRROR NEURONS PSYCHOANALYSIS: PROJECTIVE IDENTIFICATION SOCIAL PSYCHOLOGY: EMOTIONAL CONTAGION

43 Emotional Transfer ・ Neumann R ・ Neumann R, Strack F. 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.J Pers Soc Psychol Aug;79(2):

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

45 BE A GENIUS

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48 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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