Transcript MIND - AFFECT - BODY AFFECT AND SCRIPT IN MEDICINE

MIND - AFFECT - BODY
AFFECT AND SCRIPT
IN MEDICINE
General Overview
GOAL:
Integrate affect into general
clinical medicine.
Particularly Primary Care
What are the impediments?
How can we overcome them?
How have I tried to overcome
Obstacles?
Overview of present
environment.
Medical and economic milieu
and attendant impediments.
To change the system seems
overwhelming.
But there is growing recognition
of the importance of unifying
mind and body.
At least since 1946 we have
tried to officially recognize
the link between mind and
body as exemplified by:
The WHO organization's
definition:
“The complete state of physical,
mental, and social well-being
and not merely the absence of
disease."
Or as I often present it to people,
and taking it a step further,
AT is about normal physiology
and psychology
There is really no abnormal.
The organism is always
responding the best it can for
the circumstances.
But using the disease model
we generally recognize that
many diseases have a
mind-body connection.
We have always explored
the spiritual connection to
health and searched for a
‘Holistic Medicine.’
We are told that depression, alcohol
and drug use, anxiety, sleep problems,
chronic fatigue, back pain and
various somatic symptoms have at
least some ‘mental’ component.
Many recognize that these can
and should be addressed in a more
‘holistic’ fashion in primary care,
However, they often go undetected
or are treated mechanistically.
Leads to statements such as ‘there is
nothing wrong with your back.’
Patient: ‘But doctor I have back pain.’
Doctor: ‘There is nothing wrong with
Your back.’
We are in the historical
process.
Why is the system not more
coherent?
1999
First Surgeon General’s
report on mental health.
“This report recognizes the
inextricably intertwined
relationship between our
mental health and our
physical health and wellbeing.”
“We recognize that the brain
is the integrator of thought,
emotion, behavior, and
health….. “
“……the extent to which it
has mended the destructive
split between“mental”
and“physical” health.”
“Today, the majority of those
who need mental health
treatment do not seek it. The
reluctance of Americans to seek
and obtain care for mental illness
is all too understandable, given
the many barriers that stand in
their way. “
IMPEDIMENT
Massive Withdrawal
“Individuals should be
encouraged to seek help from
any source in which they
have confidence.”
"For adults and children with
less severe conditions, primary
health care, the schools, and
other human services must be
prepared to assess and, at times,
to treat individuals who come
seeking help.”
"Primary health care could
be an important portal of
entry for children and
adults of all ages with
mental disorders. “
"For the general public,
primary care represents a
prime opportunity to obtain
mental health treatment or
an appropriate referral.”
“Yet primary health care
providers vary in their
capacity to.. manage mental
health problems. Many
highly committed primary
care providers do not know
referral sources or do not
have the time to help their
patients find services.”
This talk is about placing
affect in the medical model
and the attendant problems
in doing this.
So a bit more orientation:
Medicine is a huge enterprise.
I will talk about my area.
Again ‘Primary Care’ and
particularly Family Practice.
What is Primary Care?
It is usually thought of as Family
Practice,
Pediatrics and Internal
Medicine. OB-Gyn in most
places are also recognized.
Large and deep issue in Western thought:
The medical system that came out of this
history:
• Based on specialization
•Based on academics
•Based on the scientific boon of the 20th
century
•Based on deconstructing the body.
I often say that we are not
really even one profession
any more.
I have very little in common
with a cardiovascular
surgeon.
Only the still present GP and
Family Practitioner are
really at all equipped as a
group to see the patient in
their entirety.
Mental Health
Where does it fit in
medicine?
First of all care is
fragmented as we
all know.
Settings:
Private therapy
Marginalized care
County-State MH Dept.
Medical Practice
50% psychiatry
Family Practice
We have a world of
DSM
and
Tomkins
And of course no one
knows about Tomkins.
This, of course, is
no small problem.
On the other hand there is
really nothing ‘unifying’ out
there.
Look at BOL the Internet site.
The Behavioral Science in
Primary Care site has very
poor participation as does
Ethics, Law and Psychotherapy.
So:
Recognition of mind-body problem.
Recognition that we are going
towards a solution.
Recognition that solution needs
to involve primary care.
Recognition that the metal
health system and medical
system are fragmented.
Basics of medical education:
MEDICAL SCHOOL
Major mental disorders.
Biological model.
RESIDENCY
Most have no contact or
exposure except grand rounds.
Or you are exposed to only
severe mental health problems
that scares you away.
MANAGED CARE:
Major impediment.
Fragmented care.
Limited care. We all know this.
As for primary care they expect that you
are not going to do the mental health and
therefore will not pay you.
Or if they find out you will do it
they will send patients to you
instead of the psychiatrist and
pay you less.
These are real problems.
Some areas have upwards of
80 per cent managed care
penetration. Not all providers
can ignore them.
Public perception
The quick fix problem that does
indeed exist.
People do have busy lives and do
feel they can’t slow down to get
help.
Stigma
Shame
Resistance to medication
Confusion about how to enter
system
Able to tolerate ‘physical
diagnosis’ rather then
being ‘crazy.’
Nurse Practitioners
and huge number of
people coming in as
entrepreneurs with no
medical background.
Medication as an impediment.
Not sure why therapists
want prescription
privileges!.
Job Offer
So again mpediments are
many:
Overall system
No insurance
Managed Care
Stigma
Competition
Lagging educational system
Deep historical and
philosophical reasons.
For where we are.
To really address these issue we
would have to look at much deeper
into Western thought at least going
back to the Greeks.
Descartes, modern and post modern
thought. All of it caught pretty much
up with reason. -Little about
emotion.
With the introduction of such
systems of thought such as
Geometry we start on a long road
of abstracting the physical world
including our own bodies.
Descartes:
He wanted to purge reason of the
passions.
Thing is he admitted he couldn’t yet
we continued thinking he did as The
Algebra and Calculus where and are
so powerful.
Isn’t it true that when we first
introduce people to AT they will
object that when we do math we
do it with pure reason.’
So we all know there are great
cognitive castles built up that
are great impediments.
Overcoming Impediments
Again what can we say about
physical problems being
connected to the mind?
More specifically what do
we know about the mind
body connection.?
Leading causes of death
have strong affective
links.
CHOLESTEROL, OBESTIY,
SUICIDE, DRUG ABUSE,
ANGINA, HYPERTENSION,
CHIRROHSIS, TRUAMA
All of these have at least
a major emotional and
cultural component.
Attack self scripting:
Study showed huge percentage
of patients doing something to
sabotage care.
The blue area represents where
I think most medical patients
fall.
The red area represents where I
think most physicians fall.
Solutions?
Lets look at an example of
specialty care:
Dr. Lance Gould in Huston
Use of IMAGE via
PET SCANS
Patients are highly
motivated.
Image plus, drugs,
diet (Dean Ornish)
They admit that patients
are motivated.
They recognize that it is
time intensive and not
reimbursed.
The missing link is how do we
motivate those that are not,
the ones that are passive?
I think by first
teaching about affect.
What do I do?
My job is different from the
regular therapist.
Simply someone can come to me
for anything.
But everything has an affective
component.
Although I do ‘traditional’
therapy.
For the medial patient initially
they have no idea of the role of
affect or it is hidden just under
the surface.
Patient comes in with a ‘boxer’s
fracture of the right hand.
He hit a wall and broke is hand.
I took 20 minutes giving him
some idea of what was really
going on.
Did I do any good?
So how do I bring it up?.
If you go looking you will find
an affect problem almost
always.
This is Family Practice
What defines Family Practice?
We might say affect.
We are on the front line.
The history is almost always
affectively charged.
People are fighting fear.
Always minimizing.
But what do I do?
I write down the nine words.
I ask if any of them are
‘bothering them.’
I go through the
Compass Of Shame
Then I see what happens.
I will usually spend at least an
hour and try to get them back
soon for the second hour.
HOME WORK
The ‘medical’ problem often
drops into the background
but it is not ignored.
JOSE AND HYPERTENSON
treatment. They can in fact kill us.
So unlike traditional therapy
which is limited to a fairly well
defined contract for services.
.
Medicine is not the same.
I see what I am doing then as
Model for applying AT to the
larger world .
And within medicine I have had
the privilege of apply AT in
various settings..
Traditional doctor patient visit.
Group therapy
Sheltered workshops
Schizophrenic shelters
Nursing homes
Precepting medical students
Teaching Medical Ethics
Substance abuse
Groups
Hospital detox
Summary
Western culture can be see as a
long history of separating
mind and body. .
All our institutions reflect this
fact.
Now there are many that would
like to solve this dualism as
exemplified by the WHO
statement on health and the
Surgeons General’s report.
Many impediments:
Financing
Consumerism
Continued stigma of having
‘mental problems
Again our history reflected in
physician education.
The role of medication
Surgeons General’s report.
Infighting and truf battles
But many are trying creative
ways of unifying mind body:
Such as Dr. Gould in Huston
But Tomkins does it better.
Impediment:
Few know of him.
At least I think I have shown
that it can be integrated into
medicine and that it works.
But on the other hand maybe
only real and massive change will
come through such a early public
and preventative health program
such as Dr. Nathanson’s school
program where, as he says, we
can immunize children.