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PubMed1979

General psychiatry, primary care, and medical primacy.

Nonmedical psychotherapists are able to present themselves to the public as psychiatrist-equivalents, except for prescribing drugs, because psychiatrists have neglected to emphasize the nature of medical responsibility, here called "medical primacy." Psychiatric identification with the psychoanalytic and public relations models is criticized. Three cases are presented to illustrate the functioning of the general psychiatrist as a primary care specialist. It is acknowledged that all psychiatrists may not be attracted to this role, which intersects certain transference and countertransference vectors.

Adult↗
PubMed1979

The consultee-attended interview: an approach to liaison psychiatry.

The consultee-attended (C-A) interview, a format in which the liaison psychiatrist interviews the patient in the consultees' presence, is described. The background, strategy, concepts and methods, obstacles and resistances, and countertransference difficulties of C-A interview are discussed. The C-A interview is an experiential teaching instrument with which to facilitate consultees' "participant-observation," a clinical posture that complements other approaches to the care of sick people.

Adult↗
PubMed1981

The borderline patient in the general hospital.

The usefulness of the general hospital inpatient service for the borderline patient is described. The short-term nature of most general hospital units requires a setting that facilitates the rapid establishment of a holding environment and the re-establishment of self-object transferences. Borderline patients have particular difficulty in accepting responsibility for their feelings and behavior and, instead, tend to blame themselves and others. An approach to inpatient care that defines expectations of both patient and family prior to and early in the admission of the patient is elaborated clinically and theoretically. Such an approach offers a way of working with the potential regression in borderline patients, especially around the important issues of responsibility and blaming. The staff's awareness of countertransference problems related to the patient and family as well as to the patient's therapist are described as important ingredients in successful work with these patients.

Attitude of Health Personnel↗
PubMed1986

Psychiatric consultation with general hospital chaplains.

This article describes a program in which psychiatrists serve as consultants to a group of chaplains working in a general hospital. The chaplains learn to use specific concepts and techniques from liaison psychiatry to evaluate and refine their own work. The consultants teach them about psychopathology in the medically ill, about the awareness and use of transference and countertransference reactions, and about how to define an appropriate role within the medical ward milieu. The article discusses the benefits of this consultation to chaplains and psychiatrists, especially in clarifying the role distinctions between the two groups.

Chaplaincy Service, Hospital↗
PubMed1988

Reverse liaison rounds with a burn unit case.

A liaison rounds is presented, one attended by all members of a consultation-liaison (C-L) team along with the medical director of a burn unit. This structure is designated as a "reverse liaison rounds," as it is the opposite of the conventional liaison meeting, which consists of one C-L consultant and the total nonpsychiatric team. The content centered on a self-inflicted burn case in which countertransference issues involved a nonpsychiatrist. The unconventional format of the reverse liaison rounds provided all parties with new knowledge, perspectives, and insights into the interactions between the C-L consultant and the burn unit team.

Adult↗
PubMed1994

Psychotherapy of the otolaryngology patient.

Psychotherapy is an essential skill in the treatment of the medically ill patient. It represents to a significant extent the manner in which we understand and intervene in the patient's efforts to cope with overwhelming loss and grief. Psychotherapy of the Otolaryngology patient is especially challenging because of the substantial impediments to communication in this population. This paper will review some of the special issues that apply to many medically or surgically ill individuals but which are almost universal to the Otolaryngology patients. In particular the special topics of "Body Image" including disfigurement and cosmetic surgery, and "The Role of Verbalization" will be discussed. Consideration is also given to the special topic of countertransference which is also encountered in psychotherapy in reaction to these patients.

Body Image↗
PubMed1988

Cocaine psychosis and AIDS: a contemporary diagnostic dilemma.

This article examines some of the differential diagnostic considerations associated with the interaction between advanced cocaine psychosis and the neuropsychiatric manifestations of AIDS-Spectrum Disorders. A clinical case is presented to illustrate the potential for institutional countertransference in the treatment of substance abusing patients. The role of a multi-dimensional hypotheses testing model in cocaine related cases is discussed.

Acquired Immunodeficiency Syndrome↗
PubMed1989

Individual psychotherapy with mentally retarded individuals: a review and call for research.

Although most mental health professionals doubt the capacity of mentally retarded patients to benefit from psychotherapy, a review of case studies, writings, and research revealed that mentally retarded patients responded positively to treatment. Practitioners familiar with this population developed six major recommendations for adapting psychotherapeutic approaches to mentally retarded patients. In order for therapy to be successful, it is recommended that clinicians adapt standard technique to the patient's cognitive level, be directive in approach, be flexible during therapy, engage significant others in the therapeutic process, carefully manage transference and countertransference issues, and directly address the issue of mental retardation as a disability. The results of three research studies suggested that mentally retarded patients benefit from psychotherapy, although a fourth study showed negative results. There is a great need for systematic research to develop a knowledge base to support the growing applications of psychotherapeutic methods to this population.

Humans↗
PubMedDate not supplied

Concurrent medical illness in the schizophrenic patient. Epidemiology, diagnosis, and management.

The management of the medically ill schizophrenic patient presents a dual dilemma for the physician. The patient may have a serious medical illness that must be diagnosed and effectively treated, yet the patient's psychiatric disorder may interfere with effective management. Thus, undiagnosed and untreated medical illness can result in significant morbidity for schizophrenic patients. Because schizophrenic patients may appear to be less cooperative than medical patients without concurrent psychiatric illness, they can cause countertransference reactions on the part of physicians and nursing staff that can interfere with treatment. Schizophrenic patients also have deficits in the processing of sensory information. These deficits require the staff to make changes in management in order to facilitate the patient's ability to cooperate with treatment and to give reliable informed consent. A host of other factors complicate the medical management and treatment of schizophrenic patients. Such factors include medication side effects of psychotropic medication, the potential interactions between medications used to treat the patient's physical illness with psychotropics, pregnancy in the female patient, and the strength of the patient's support system. The ability to successfully diagnose and treat concurrent medical illness in the schizophrenic patient will depend on the physician's ability to be flexible and to understand the implications of the patient's underlying disorder for his relationship to hospital staff. This paper reviews some of the relevant literature and describes possible treatment strategies integrating what we know about schizophrenia with medical management.

Adult↗
PubMed2005

Diagnosis and psychiatric treatment of athletes.

Although enormous amounts of time and money have been invested in enhancing performance for college and professional athletes, their psychiatric needs have been minimally addressed. Given the virtual absence of controlled scientific literature, in this article the authors detail the diagnostic issues and delineate treatment principles, including: (1) making an accurate diagnosis; (2) setting realistic goals; (3) delivering psycho-education; (4) inducing the patient to undergo treatment, including involving the family and significant others; and (5) delivering appropriate treatment (the most difficult task). The objective is to improve performance and quality of life by treating the problem or psychiatric illness. A special concern is minimizing countertransference feelings and avoiding undertreatment, because by definition the athlete needs to perform.

Adult↗
PubMedDate not supplied

The therapist and the patient: coping with noncompliance.

In the mental health clinic, the psychotherapist must cope with a multitude of diagnostic and therapeutic challenges. Extensive efforts are expended in reaching a diagnosis and a decision regarding treatment. Despite these efforts, the patient may fail to comply with the recommendations for treatment. Noncompliance has a wide variety of manifestations. One of the major reasons for noncompliance concerns the relationship between the patient and the physician, forcing the therapist to take an active part. Manifestations of noncompliance usually arouse countertransference reactions in therapists, who feel that this behavior exemplifies a lack of trust in them and in the corpus of knowledge they represent. Unique to the therapist's work in the mental health clinic is the need that sometimes arises to begin intervention before a basis for treatment has been established or an initial treatment contract achieved. In certain cases, observation is the only psychotherapeutic intervention possible. Much time may elapse until a therapeutic contract is established, and sometimes it is not established at all.

Adaptation, Psychological↗
PubMed1992

The recognition and management of somatization. What is needed in primary care training.

This article addresses the medical education issues associated with teaching primary care residents about somatization. Specific training designed to recognize and manage somatization involves a hierarchical series of five knowledge domains with associated discrete skills. As a foundation, a biopsychosocial model must be embraced by the medical leadership of the training program. Second, because psychosocial stresses play a critical etiologic role in somatization, the ability to identify relevant psychosocial issues during medical interviewing is a fundamental skill. Third, basic psychiatric diagnostic areas (depression and anxiety) must be mastered as a prerequisite for identifying somatization. Specific interviewing and management techniques are reviewed, along with two current programmatic approaches. Finally, the concept of physician countertransference also must be explicitly addressed as part of the curriculum. Without assuring that these building blocks are in place, residents are likely to become overwhelmed by the management of somatizing patients and continue the pattern of frustration associated with these patients.

Curriculum↗
PubMed1998

The medical psychiatrist as physician for the chronically mentally ill.

A 60-year-old black female with chronic paranoid schizophrenia was admitted to the Medical Service for a workup because of severe iron deficiency anemia; she refused the workup. She was found to be acutely psychotic and incapable of informed medical decision making. The management of her medical workup by her medical/C-L psychiatrist led to a diagnosis of colon cancer, and subsequent surgery. The case is discussed here by a consultation-liaison psychiatrist and a lawyer bioethicist. It illustrates the role of medical/C-L psychiatrists as physicians for chronically mentally ill patients with serious medical illness in the general hospital, who guide the medical/surgical care of these patients without powerful negative countertransference bias, thus balancing respect for patient autonomy with advocacy for medical "best interests."

Adaptation, Psychological↗
PubMedDate not supplied

Captive patients, captive doctors: clinical dilemmas and interventions in caring for patients in managed health care.

This article explores common clinical dynamics resulting from the denial of choice that many patients experience in managed health care and proposes clinical adaptations for the treating or consulting psychiatrist. Patients who feel they have been denied the right to choose their health plan, treatment setting, or personal physician commonly go through a subjective experience analogous to that of being held captive. This sense of captivity can exacerbate the feelings of helplessness and hopelessness brought on by serious illness. It can also intensify the patient's feelings of alienation and betrayal when managed care constrains patient-physician decision making by limiting treatment options. These dynamics can lead to identifiable transference reactions and, in turn, to physician countertransference. Psychiatrists can do much to ameliorate these potentially destructive dynamics both as treating therapists and as consultants to general physicians. Indications for consultation or intervention are analyzed and specific clinical strategies to enhance the patient's decision-making capacity throughout the introductory, ongoing, and termination phases of the treatment alliance are reviewed.

Health Maintenance Organizations↗
PubMed2002

Post-termination sexual boundary violations.

In this essay, the author has focused on the rationale for an absolute prohibition of sexual contact between psychiatrists and former patients. The role of an ethics code is to proscribe professional misconduct that may have the potential to harm the patient. Because we know that in many cases of psychiatrist-patient sex there is serious exploitation of the patient's vulnerability, we have clear prohibitions against sexual relations between a current patient and his or her psychiatrist. The same considerations apply to former patients. The transference (and countertransference) feelings established in the relationship persist well beyond termination. Even in the absence of a treatment that acknowledges the existence of transference, a power differential is unmistakable because of the fiduciary nature of the relationship. Moreover, the therapeutic relationship is effective because it will never be anything but a treatment relationship. The possibility of a future sexual affair between psychiatrist and patient erodes the conditions necessary for effective psychiatric therapy. Finally, most patients will feel the need to return to treatment at some point in the future, and the psychiatrist needs to preserve that potential as part of the duty to the patient. For all of these reasons, the current position of the APA on an absolute prohibition against sex with former patients is a sound and sensible one.

Humans↗
PubMed1999

Victimization of women and its impact on assessment and treatment in the psychiatric emergency setting.

An understanding of victimization is critical to the practice of emergency psychiatry. Victimization histories are disturbingly common among women presenting to the PES, particularly among frequent service users. The sequelae of victimization are both psychological and physical and often impair health and functioning across numerous domains. PTSD, BPD, and substance-use disorders are often seen among women with victimization histories, which can be particularly challenging for PES providers. Screening for trauma on PES presentation or history should not be overlooked in any person, including severely mentally ill, homeless, disabled, or elderly women. PES clinicians should remember to ask about victimization and pose questions privately in a direct and an open-ended format while conveying empathic validation. Clinical assessment of women with victimization histories in the PES should be guided by the principles of standard emergency psychiatry and be informed by an understanding of trauma. This includes a working knowledge of trauma dynamics, adherence to sound professional boundaries, and care not to retraumatize patients or re-enact perpetrator-victim dynamics. Voyeurism and regression should be avoided, particularly when eliciting trauma history. The PES should be a place for screening and acute intervention, not for conducting intensive trauma therapy. In the PES, the focus should remain on triage and treatment priorities, those of safety and stabilization, and carefully evaluating for substance use and psychosis. The PES ideally provides a "holding environment" that affords a balance of nurturing, limits, consistency, and communication. A basic knowledge of cognitive-behavioral interventions affording "crisis survival strategies," such as DBT, can be particularly useful to PES clinicians. Clinicians also need to monitor issues of countertransference and the potential to be dismissive to these women with complex, comorbid, and chronic problems and diseases. The role for the use of psychotropic medication in PES cohorts with victimization histories should target acute symptoms. Involving regular providers of these decisions is advised to coordinate care and minimize splitting and risks of polypharmacy. Although the SSRIs are effective in symptom management of disorders related to victimization, patients must be reminded of the side-effect profile, particularly sexual dysfunction and withdrawal and discontinuation syndromes.

Age Factors↗
PubMed1996

Feminist psychodynamic psychotherapy of eating disorders. Theoretic integration informing clinical practice.

Ideas derived from feminism and psychoanalytic theory can be combined for the integrated treatment of eating disorder patients. For a large subgroup of patients who continue to have a poor quality of life or inadequate symptom control (despite customary psychopharmacologic and cognitive behavioral interventions), feminist psychodynamic psychotherapy may prove lifesaving. This article explores how the patient may come to grasp more deeply the multiple roles her symptom has played in her psychological survival. Practical suggestions to enrich the psychotherapy as the patient traverses the natural struggles of adult life are emphasized. The importance of understanding and working with transference and countertransference issues while helping the patient accept life's paradoxes, ambiguities, and potential avenues for growth are underscored. The author reviews eight specific areas that warrant attention in psychotherapeutic exploration from a feminist psychoanalytic perspective (Culture as Bedrock Issue; Gender as Organizer of Behavior, Ownership of Body; Moral Development; Development of Personal Voice; Emphasis on Adult Development; Sexual Concerns; and Aggressive Conflicts).

Culture↗
PubMed1999

Reflections on volatile substance dependency treatment. Negotiating the boundary between inner and outer reality.

A brief review of the causal and treatment literature relating to volatile substance dependency suggests the interaction between individual and system requires careful attention and understanding. A model is tentatively and provisionally adumbrated to help clarify the main factors involved from a dynamic biopsychosocial perspective. Ego boundary disturbances emerge from and reciprocally influence behaviour and social interactions. These disturbances can be avoided temporarily, although inevitably deepened in the long-term, by substance dependence. Two case examples, selected because they differ in many respects, including relative treatment effectiveness, illustrate this integrative perspective. The discussion focuses on explaining the differing outcomes in terms of the extent to which the inner-outer boundary is open to modification and how far it can be successfully negotiated and clarified. A major factor in differentiating between inside and outside is thought to be causal perceptions or "attributions." Successful differentiation tends to facilitate change, as opposed to reinforcing maladaptive homeostasis. Key issues for therapists overlap with addictions treatment in general, including emotional blocks or barriers in patients, difficulty engaging systems in a strategic manner, and countertransference problems. It is argued that these difficulties in therapy might respond to integrative psychotherapeutic responses, provided the differences in perspective are sufficiently understood.

Administration, Inhalation↗