Transcript Psychic crisis

Ethical problems of
approaching a patient with
psychic crisis
Mgr. Miloš Mauer
Dep. of Ethics, 3.LF UK Prague
Psychic crisis - definition:
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Subjectively endangering situation with great dynamic charge and
potencial for big change
Previous coping mechanisms are now insufficient
Intensity is not given only by the stimulus itself, but also by his
value, interpretation, which can be unconscious
There is no psychic stresor which is independent on man
Doesn´t correspond exactly with diagnostic criteria, like for
example „Acute stress disorder“, because of limitation of this
diagnosis and because crisis has allways more levels than only
medical one.
Crisis is more process than stable state (which could be simply
described by diagnosis).
Acute stress disorder (ICD 10)
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Transitory disorder as a response to unusually big stress
stimulus
Symptoms are obvious after one hour after the event
and lasts up to three days, sometimes there is amnesia
afterwards
There are couple of symptoms connected, like
avoidance behaviour, dezorientaton, narrowing of
perception (tunnel perception), anxiety a many possible
emotional states like anger, grieve etc.
Psychic crisis
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Chinese sign (concept) for „crisis“ – „Wej-ji, has parts which mean „danger“ and
„good opportunity“, other meaning of the sign can be „gorge“ (narrow pass).
Many of us have for example experience with dreams, which are reflecting some
critical situations in our lives. Dreams about falling, not being able to move or act,
dreams where we are in danger, persecuted, etc.
Crisis can be also described with help of the concept „middle ground“ (Biosynthesis
psychotherapy). Imagine the moment of your walk, when one leg is leaving the ground
and the other one didn´t step on the ground yet. This is like crisis, moment of
instability (In that moments there are for example magical bridges in some fairy-tales,
they apper only if you walk on them).
Crisis means that your world, where you live and which you understand somehow, is
changing now and the same is happening with your identity. So it means great danger
for you, instability, feeling not to be safe. It also means great opportunity for good
changes in our life. Many people experienced positive changes in their lives as a
consequence of some crisis.
Every crisis is existencial situation, which has physical, psychological, social and
spiritual level. It means that it widely extend beyond narrow field of medicine. Coping
with critical moments in our lives, we are becoming ourselves, developing our true self
and also we are becoming mature man and women.
Posttraumatic growth
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Life is paradoxical, many times without some crises or big obstacles we are
not able to move forward, to make substancial changes in our lives. Without
painful delivery and our great effort to go through birth canal, for example,
we wouldn´t be in this world.
Calhoun and Tedeschi (2006) pioneered the concept of Posttraumatic
Growth (PTG), a construct of positive psychological change that occurs as
the result of one’s struggle with a highly challenging, stressful, and traumatic
event. Some of these pople can experience enriching of their lives.
Posttraumatic growth theory does not suggest that there is an absence of
suffering as wisdom builds, but rather that appreciable growth occurs within
the context of pain and loss.
Along with growth or wisdom-building, the fruits of PTG may also include a
preparedness or “resilience” for future events that may otherwise be traumatic
(Calhoun & Tedeschi, 2006 )
PTD is, however, quite rare and depends on the speicific situation of crisis,
personality, but also on the reaction and help of others.
Typology of crisis
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Situational crisis
Crisis connected with traumatizing factor (stronger than
situational crisis). Theory of life events – Holmes and
Rahe (1967)
Transitory or developmental crisis – crisis connected
with expected life changes (demands of growth and
maturing): for example delivery of baby, menses, first
sexual experiences, adulthood, marriage, menopause,
andropause, crisis of middle age, senior crisis
Crisis connected to psychopathology
Cause and trigger of crisis
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Trigger is situation, when crisis starts. It can be also cause of the crisis, but
sometimes is not.
Trigger can be sometimes only „last drop“, when there is long cumulation of
stress
Trigger can starts crisis, because some situation resemble other situation in
the past, which was so far suppressed and which is the cause of the crisis
In that moment we talk about delayed break down, which si sometimes called
also anniversary syndrom (crisis starts on the date of anniversary of some bad
situation in the past).
Theory of life events (Holmes and Rahe, 1967)
Confusing cause and trigger by medical stuff often cause misunderstanding
of patient, inadequate treatement, or even blaming him being hypersensitive,
hypochondriac, weird and so on.
Crisis intervention:
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Short duration
Concetration on actual situation (process)
Working with broader social system of patient (family for example)
Focus on the problem, not on the diagnosis
It is not only solving of problems, but also supporting people to be
competent to solve them
Principles of competency, abreaction, presence, education
Principles of dead and live water (Goldilocks fairytale)
Working with the resources of patient
Strenghtening psychic integrity
(support of ego-defence mechanisms).
Usual phases of crisis
1. Shock (1 – 2 dny)
2. „First cry“(up to 3 days)
3. Thinking about meaning, guilt and shame
(3 days – 2 weeks)
4. Reexperiencing/suppresion (2 weeks – month)
5. Posttraumatic phase (development of PTSD, further
suppresion or recovering) (1 – 3 month or more)
In between phases of redefinitioning of crisis
Working with resources of patient,
strenghtening of competence and psychic
integrity
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- family, partner, friends, community
- material background
- life experiences, memories
- cultural background, faith, values
- ability of interpersonal contact
- ability to perceive and communicate one´s feelings
and emotions
- experiences of personal strength and competence
under heavy stress
Specific stress reactions
BASIC QUESTIONS:
Integration or desintegration?
Activation or inhibition?
Are particular emotions expression of inner state,
or defense against real inner feelings and
emotions?
Alfa stress reaction (fight or flight)
Beta reaction (inhibition, „playing dead beetle“).
Specific stress reactions
Basic emotions:
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Despair, hopelessness, sorrow, grieve (often crying)
Anger
Fear
Disgust (shame, guilt)
Other typical reactions, most of them can be also
consequence of suppresing of emotions
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Anxiety, agitation, hyperactivity, panic
Dissociation, suppresion, derealization, depersonalization
Somatization
Regression
Freezing, reactive depression
Quantitative or qualitative changes of consciousness
Suicidal tendencies
Presuicidal syndrom
(E. Ringel)
narrowing of subjective space
 blocked aggression or aggression targeted
inside
 pressing suicidal phantasies
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Ethical problems of approaching
patient in psychic crisis
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Doctors and nurses often underestimate importancy to approach differently
patient in crisis and consequences of the crisis on the health (usually its
deterioration) of the patient. They often do not recognize, that basic crisis
intervention is also integral part of their work and no only of some other
specialist (like psychologists). Principle of Beneficence means to relieve
suffering and suffering is often experinced as a crisis.
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Psyché (soul) is commonly perceived in medicine as non-important. So are
emotions, together with european philosophical tradition they are perceived
as something bad, which must be controlled, supressed. However, appropriate
expression of feelings and emotions (positive and also negative ones) is
integral part of human health, not their suppresion, this is described for
example in „coactivation model of healthy coping“ (Pennebaker 1993,
Larsen 2003). Spirituality is so far often neglected in medicine. Emotions,
when handled properly, have also cathartic affect (old greek – catharsis means
purification).
Ethical problems of approaching
patient in psychic crisis II
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Social iatrogenesis (Illich, I. 2002): - medicine make people dependent on
the health care even in the situations, when they can handle situation by their
own forces. Medicine doesn ´t teach people how to prevent or copy with
crisis moments in their lives with the support of natural resources
(community, personality strenghts, spiritualiy, life style etc.).
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Cultural iatrogenesis (Illich, I. 2002): Medicine doesn ´t situate pain and
suffering into some meaningfull context, in opposite these phenomenons are
underestood as arbitrary and without any meaning, except biological. Pain and
suffering is, however, more tolerabile, when we perceive it as meaningfull.
Medicine is also sometimes in war against every suffering without
distunguishing, which suffering should be trated as a illness and which not.
People than loose ability to cope with suffering and are dependent only on
the pharmaceutical for example.
Emotions in medicine
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Suppresion predominate! ( often pharmacological), because it slows down
treatment (seen as purely biological), brings emotional load to medical stuff.
However – low emotional support is main thing, which patients criticise on
medicine, for example in last research of quality of care in faculty hospitals in
Czech republic (MZ ČR 2009, Kvalita očima pacientů, Fakultní nemocnice a
ústavy).
Suppresion predominate, because working with emotional patient is hard.
Working with emotions for example doesn ´t mean, that patient get well just
as he/she starts to communicate about his/her feelings. Sometimes this
opennes brings temporarily worsening of his/her state. But only by this way
he/she can be able to cope with the emotions a then feel really better.
By suppresing emotions there „becomes inner desert of emotional life, which
correspond to the outer desert of ecological horror, with which we endanger
the whole planet“ (D. Boadella, 1993).
Transitory/developmental crisis
Cultural background – rites of passage (A. van
Gennep, 1960)
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Rituals are helping get through difficult stages
of life, when there is a change of identity and
social status
There is strong support of society (community)
Rituals are bringing structure, and it means sense
of stability a comprehensibility, they regulate
strong emotions connected with this passages.
There are many examples of „cultural heroes“
or ancestors, which help with the passage.
Rites of passage - examples
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Pregnancy, birth (circumcision, puerperium, baptism
etc.)
Menses, Pubescence, becoming adult - initiation rituals
Marriage
Menopauze, Andropauze
Death, dying
Time passages (solstice, euqinox, new year, new moon,
easter – pesach, etc.)
Passages between various levels of reality –
sacred/profane, men/women, home/abroad,
illness/health etc.
Iniciation rituals
separation from other sex, or from the tribe, symbolics of
death and being new born, sometimes connected with
journey to the underworld, being devoured by some creature
(Jonas in the bible) etc.
 iniciation into the mythology and stories of the community
 trials (pain, will), ritual restrictions (feasts, prohibition of
some activities) , specific symbolic task (cave paintings,
hunting a animal etc.)
 change of identity (new name)
 altered states of consciousenss
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Iniciation rituals today
maturity, study
 dancing courses
 travelling (au-pair), outdoor
 clubs
 tattoo
 military service
 some specific cultural phenomenons (phantasy movies)
 religious experiencies
 illness
 altered states of consciousness – drugs, music, meditation, prayer,
sensoric overload (technoculture) or deprivation, adrenaline activities,
car driving, spontaneous existencial states etc.
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Example of posttraumatic growth
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Hunter Doherty "Patch"
Adams (born May 28, 1945,
in Washington, D.C.) is an
American physician, social
activist, citizen diplomat,
clown and author. He
founded the Gesundheit!
Institute in 1971. Each year
he organizes a group of
volunteers from around the
world to travel to various
countries where they dress as
clowns in an effort to bring
humor to orphans, patients,
and other people.
Example of posttraumatic growth
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Adams had a difficult childhood. His father, an officer
in the United States Army, had fought in Korea, and
died while stationed in Germany when Adams was still
a teenager. After his father's death, Adams returned to
the United States with his mother and brother. Upon
his return, Adams has stated that he encountered
institutional injustice which made him a target for
bullies at school. As a result, Adams was unhappy and
became actively suicidal. After being hospitalized three
times in one year for wanting to end his life, he decided
"you don't kill yourself, stupid; you make revolution."