ea LESSON 1: DOCTOR — PATIENT RELATIONSHIP Listening : the key skill in Psychiatry © Key Listening Skills © Hearing ~Connotative meaning of words, Idiosyncratic uses of language, Figures of Speech that tells a deeper story, voices, tones, modulation, stream of association Seeing — Posture, Gestures, Facial Expression Comparing ~ Noting what is omitted, Dissonances between modes of expression Intuiting — Attending to one’s own internal reactions Reflecting — Thinking it all through outside the immediate pressure to respond during, the interview + Blocks to Effective Listening © Patient-Psychiatrist Dissimilarities: Race, Sex, Culture, Religion, Regional dialect, Individual differences, Socioeconomic class © Superficial similarities : May lead to incorrect assumptions of shared meanings © Countertransference: Psychiatrist fails to hear or reacts inappropriately to content reminiscent of own unresolved conflicts © External Forces : managed care settings, Emergency Department, Control oriented inpatient unit © Attitudes : Need for control, Psychiatrist having a bad day ‘+ Attitudes Important to Listening (©The centrality of inner experience ‘There are no bad historians ‘The answer is always inside the patient Control and power are shared in the interview It is OK to feel confuse and uncertain Objective truth is never simple as it seems Listening to yourself too Everything you hear is modified by the patient's filter Everything you hear is modified by your own filters ‘There will always be another opportunity to hear more clearly e000 000000000 Roles and Motivations ‘* The physician- patient relationship includes specific roles and motivations. ‘+ These form the core ingredients of the healing process ‘+ Ingeneric form the physician- patient relationship is defined as coming together of an expert and a help seeker to identify and understand, solve the problems of the help seeker. ‘+The help seeker is motivated by the desire and hope for assistance and relief from pain ‘A physician is required to have a genuine interest in people and a desire to help The relationship between the physician and the patient is essential to the healing of many patients , itis critical to the therapeutic outcomeFormation of the Physician-Patient Relationship Assessment and evaluation Rapport Therapeutic working alliance Transference and countertransference Defense Mechanism Mental status of the Patient ASSESSMENT AND EVALUATION The physician and patient relationship develops during the assessment and evaluation of the patient, The patient observes the thoroughness and sensitivity with which the physician collects information, performs the physical exams and explain the needed tests. At each step, the physician's clarification of the treatment goals and interventions either builds up the patient’s expectation of help and feelings of safety or creates increasing distress and disease for the patient. ‘Alertness to the patient's fears and misunderstanding of the evaluation process can minimize unnecessary disruptions of the relationship and provide information on the patent's previous ‘experiences with medical care and important authority figures. RAPPORT The psychiatri offering help. The way of relating between the physician and the patient, the physician-patient relationship has begun. ‘The physician ability to empathize, to understand in feelings terms every patient's subjective experience. initiates the “contract” of the relationship by acknowledging the pain and THERAPEUTIC OR WORKING ALLIANCE For a patient to trust and work closely with a physician, itis essential that there be a reality based relationship. The experienced physician makes communication across the gap seem effortless, using a different “language” for each patient. The therapeutic alliance is extremely important in times of crisis such as suicidality, hospitalization, and aggressive behaviour. The therapeutic working alliance must endure in spite of what may, at times be intense, irrational, delusional, characterologic, or transference based feelings of love and hate. It must provide a stable base for the patient and physician when the patient's feelings or behaviors may impair reflection and cooperation. The alliance requires a basic trust by the patient that the physician is working in his or her best interests. ‘The development of common goals fosters the physician and patient seeing themselves as having a reciprocal responsibilitiesTRANSFERENCE AND COUNTERTRANSFERENCE Transference is the tendency we all have to see someone in the present as being like an important figure from our past This process occurs outside our conscious awareness Transference influences the patients’ behaviour and can distort the physician-patient relationship for good or ill The transference can be the elaboration of an accurate observation into the “total” explanation or the major evidence of some expected harm or loss Often the physician may recognize the transference by the pressure she or he feels to respond in a particular manner to the patient. Transference is ubiquitous Countertransference is the physician’s transference to the patient: Two types of Countertransterence: © Concordant Countertransference = The physician experiences and empathizes with the patients’ emotional experience and perception of reality. © Complementary Countertransference ‘The physician experiences and empathizes with the emotional experience and perception of reality of an important person from the patients’ life DEFENSE MECHANISM Defense mechanisms are specific cognitive process: ways of thinking that the mind employs to avoid painful feelings Defense mechanism may be more or less mature depending on the degree of distortion of reality and interpersonal disruption they lead to. The patient’s characteristic defense mechanisms, the cognitive process or coping skills used to lower anxiety and unpleasant feelings, can greatly affect the physician-patient relationship. Defense mechanism operates all the time in times of high anxiety or during a life crisis. Healthier Defense Mechanism © Sublim © Humor © Repression © Displacement © Intellectualization © Reaction formation ° ° ° o Reversal Identification with the aggressor Asceticism Altruism © Isolation of affect More primitive Defense Mechanism © Splitting © ProjectionProjective identification Omnipotence Devaluing Primitive idealization Denial Conversion Avoidance ec 00cc00 MENTAL STATUS OF THE PATIENT ‘+The patient's mental status is a major determinant of the formation and nature of the relationship with the physician. ‘* The ability to work with an empathic listener while confronting limitations and feelings of shame and embarrassment is a special opportunity of a well formed patient-doctor relationship. PHASES OF TREATMENT ‘©The treatment phase: © Early : involves developing rapport, forming shared initial goals, and initiating working, alliance. * Education of the patient is important to the success of the doctor patient relationship, so that patient can learn what he or she can expect © Middle: the physician and patient continuously refine their shared goals, and various interventions are tried Transference and countertransference are likely to emerge "How these are recognized and managed is critical to whether the relationship continues and is therapeutic (© Late : the assessment of the outcome and plans for the future are the primary focus The physician and the patient discuss the end of their relationship in a process known as termination. = Success and disappointments associated with the treatment are reviewed. + The therapeutic alliance is strengthened in this stage when the physician accepts expressions of the patient's disappointments, encourages such expressions when they are not forthcoming, and prepares the patient for the future. © Factors affecting the Physician-Patient relationship: © Phases of treatment: Early, Middle, Late © Treatment setting © Transition between inpatient and outpatient treatment © Managed care © Health and illness of the physicianLESSON 2: PROFESSIONAL ETHICS AND BOUNDARIES + Medical professionalism : is demonstrated by what physicians do with patients and within their communities. © These physician behaviors include responding to and advocating for the needs of patients of patients, promoting the welfare of public health and honourably representing the profession © The values that have been associated with the profession of medicine include: service, altruism, duty, advocacy, respect, honesty, integrity, excellence and accountability. © Questions to guide clinical decision making: © BENEFICENCE : what is goad for the patient © NONMALEFICENCE: would this cause harm to this patient © AUTONOMY: what does this patient want © JUSTICE: Is this fair ‘SUMMARY OF THE WPA GUIDELINES REGARDING THE ROLE OF THE PSYCHIATRIST ON SPECIFIC ETHICAL Issues: ‘* EUTAHNASIA : use caution regarding actions that could lead to the death of those with mental illness © TORTURE: should not take part in any mental or physical torture * DEATH PENALTY: should not participate in executions or assess competency of those to be executed ‘+ SELECTION OF SEX: should not participate in decisions to abort for the purpose of sex selection ‘+ ORGAN TRANSPLANTATION: helps patients exercise self determination in organ transplantation, and avoid use of psychotherapeutic skills to influence the decision ‘+ ADDRESSING MEDIA: advocate for those with mental disorders, represent psychiatry with dignity, do not discuss presumed diagnoses of individuals, and be aware of the effect of discussions about mental illness on the public * DISCRIMINATION: never be involved on ethnic cleansing * GENETIC RESEARCH AND COUNSELLING: understand the impact of genetic information on patients, obtain informed consent, ensure confidentiality and protect data against misuse + ETHICS OF PSYCHOTHERAPY IN MEDICINE: be trained in techniques, use therapy as part of clinical treatment, be aware of need for informed consent, confidentiality and boundaries ‘© CONFLICT OF INTEREST WITH INDUSTRY: guard against gifts that influence clinical work and research trials ‘© CONFLICTS WITH THIRD PARTY PLAYERS: advocate for patients and oppose discriminatory practices towards mentally il * VIOLATING BOUNDARIES AND TRUST: no sexual relationship with patients ‘+ PROTECTION OF RIGHTS OF PSYCHIATRISTS: protect, treat and advocate for the mentally ill without undue pressure from systems and without undue pressure from systems and without discrimination toward the practice of psychiatry ‘DISCLOSING THE DIAGNOSIS OF DEMENTIA: be sensitive to the patient's rights to know and the role of family in the disease processDUAL RESPONSIBILITIES: must disclose to patient the absence of a therapeutic doctor-patient relationship at initial assessment WORKING WITH PATIENTS AND CAREGIVERS: awareness of the value of collaborating with patients and caregivers in legislation, policy and clinical practice. GUIDELINES FOR PROFESSIONAL BEHAVIORS IN CLINICAL PRACTICE Be alert to warning signs in the doctor-patient relationship that trigger self reflection. Ifa behaviour doesn’t feel right, it’s probably not, when in doubt, don’t Be aware of the nned for self monitoring and on going consultation during one’s professional career. This can occur one-on-one with a trusted colleague or in a group setting with several psychiatrists discussing their countertransference experiences and seeking input and direction for troubling cases Be sensitive to inner feelings and any behaviors that appear outside the norm when interacting with certain patients, the so called “red flags” Transfer care of patient's where there is a high potential for a boundary violation to another physician, preferably not in the same practice Consider use of an index of suspicion to identify risky behvaiors in professional conduct. Never make the patient’s problems your own Report unethical behaviors of colleagues to appropriate entities