Multiple Sclerosis and Psychodynamic Case Conceptualization

Transcription

1 Multiple Sclerosis and Psychodynamic Case Conceptualization A. Elizabeth Hirky, Ph.D. Adjunct Assistant Professor Ferkauf Graduate School of Psychology Yeshiva University, Bronx, NY Consortium of Multiple Sclerosis Centers Dallas, Texas May 29, 2014 Question: % Time Conducting Formal Psychotherapy/Interventions % % % % 1

2 % % % Question: % Time Informal Counseling/Support % Question: Which Best Characterizes Your Psychotherapeutic Orientation? 1. Psychodynamic/psychoanalytic 2. Cognitive Behavioral 3. Integrated or Eclectic 4. Family Systems 5. Other 2

3 Question: In What Setting Do You Primarily Work? 1. Neurology/Medicine 2. Mental Health 3. Rehabilitation Medicine 4. M.S. Specialty Clinic 5. Other Background & Context Large, urban, public hospital 2 inpatient rehabilitation medicine units, 44 beds Interdisciplinary Diagnoses include acquired brain injury, stroke, orthopedic and other trauma such as spinal cord injury, neurodegenerative, and amputation M. S. patients newly diagnosed, exacerbations 3

4 Mental Health Issues & M.S. Medical illness or disability requires adaptation (e.g., Moos & Schaefer, 1989) M.S. exacerbations and progression are often associated with increased emotional distress (both symptoms and disorders), both anxiety and depression (anxiety > depression) Brain lesions may be associated with increased depression while anxiety more likely reactive (e.g, Zorzon et al., 2001) How Many Psychanalytic/Dynamic Treatment Studies of Psychiatric Symptoms or Disorders of M.S. are in the Literature? > < 20 4

5 Psychodynamic Literature & M.S. e.g.: Jelliffe, S. E. (1921). Multiple sclerosis and psychoanalysis. American Journal of Medical Sciences, 161(5): Limited number Case studies Application of psychoanalytic concepts Some Current Evidence: Psychodynamic Psychotherapy Drisko, J. W., & Simmons, B. M. (2012). The evidence base for psychodynamic psychotherapy. Smith College Studies in Social Work, 82: Leichsenring, F. & Rabung, S. (2008). Effectiveness of long term psychodynamic psychotherapy, JAMA, 13: Lazar, S. (2010). Psychotherapy is Worth It; A Comprehensive Review of Cost Effectiveness, American Psychiatric Publishing. Shedler, J. (2010). The efficacy of psychodynamic psychotherapy, American Psychologist, 65, Summers, R., Barber, J. (2009). Psychodynamic Psychotherapy: A Guide to Evidence Based Practice. New York, NY: Guilford Press. 5

6 Mental Health Issues & M.S. Treating patients during an inpatient medical hospitalization requires a broad case conceptualization that accounts for the interplay between the person and the unique factors of the setting (Hunter et al., 2007) (Hunter et al., 2007) 6

7 Adaptation Model for Consultation Liaison Psychotherapy Assessment Individual Factors Present Psychopathology DSM IV interview Previous Adaptive Capacity Attachment style Developmental phase Personality Previous Stress Experience Past history of trauma Past h/o illness/hospital exper. Personal Meaning of Event Five D s (distance, dependency, disability, disfigurement, &death) Intra Hospital Environment Illness Characteristics Traumatic Impact of This Event Stress response symptoms Extra Hospital Environment Financial Resources and Housing Social work collaboration Ethnocultural Issues Language and Communication Family Relationships and Social Support Relationship survey Family interview Collateral History (Hunter et al., 2007) 7

8 Psychoanalysis/Psychodynamic Psychoanalysis has a double identity. It is a comprehensive theory about human nature, motivation, behavior, development and experience. And it is a method of treatment for psychological problems and difficulties in living a successful life. Type of treatment Theory of the mind Resources for Psychodynamic Theory & Case Conceptualization Freud, S., & Gay, P. (1989). The Freud reader. New York: W.W. Norton. McWilliams, N. (1999). Psychoanalytic case formulation. New York, NY: Guilford Press. Mitchell, S. A. & Black, M. J. (1995). Freud and beyond: A history of modern psychoanalytic thought. New York, NY: Basic Books. Messer, S. B. & Wolitzky, D. L. (2007). The Psychoanalytic Approach to Case Formulation. In The Handbook of Psychotherapy Case Formulation, 2 nd Edition, Eells, T. D., Editor. New York, NY: Guilford Press. 8

9 Hallmarks of Traditional Psychoanalytic Conceptualization Beginning with Freud s theories of personality structure and development Unconscious: Human emotion and behavior is often influences by factors outside of awareness; often involve some type of psychic conflict Maladaptive patterns have historical origins Psychological Defenses Transference & Countertransference Interpersonal Psychoanalysis William Alanson White Institute, 1943 Harry Stack Sullivan, M.D., Clara Thompson, M.D. Eric Fromm, Ph.D., Frieda Fromm Reichmann, M.D., David Rioch, M.D., Janet M. Rioch, M.D. Focus on interpersonal (rather than intrapsychic) Two Person Model Participant Observer Interdisciplinary Influences of culture & society Problems of Living (Sullivan, 1953) 9

10 What is Formulated? Temperament and Fixed Attributes Maturational Themes & Developmental Antecedents Defensive Patterns Central Affects Identifications & Relational Schemas Self Esteem Regulation Pathogenic Beliefs Adaptive Features: Assets and Strengths (McWilliams, 1999; Messer & Wolitzy, 2006) 10

11 Listening Analytically 1. Details of story 2. Defensive omissions? 3. Relationship between story and early life events giving incident its particular meaning to individual 4. Characteristic patterns of behavior? 5. Relationships revelations (about patient) from story and insights gained from psychoanalytic literature 6. Role of countertransference? (Buechler, 2008) Case: Ms. P. 34 y.o. woman, live in boyfriend, no children Myelitis diagnosis in exacerbations prior to 2013 rehab admission Imaging now confirms M.S. diagnosis Key Factors in Formulation: Chronic and Acute coping, affect tolerance, ego strengths, adaptive use of mature defenses 11

12 Case: Ms. B. 40 y.o. married woman, no children M.S. diagnosis 3 years ago Rehab admission for exacerbation Prior to admission, planning on seeing a therapist Key Factors in Formulation: Listening for Identification with family member that became key to understanding affect tolerance and potentially problematic defenses References & Bibliography Alperin, R. M. (2001). Barriers to intimacy: an object relations perspective. Psychoanalytic Psychotherapy, 18, American Psychoanalytic Association. (1990). Psychoanalytic Terms and Concepts. New Haven, CT: The American Psychoanalytic Association and Yale University Press. Buechler, S. (2008). Making a Difference in Patients Lives. New York, NY: Routledge. Drisko, J. W., & Simmons, B. M. (2012). The evidence base for psychodynamic psychotherapy. Smith College Studies in Social Work, 82, Freud, S., & Gay, P. (1989). The Freud Reader. New York: W.W. Norton. Gerber, A., Kocsis, J. H., Milrod, B. L., Roose, S. P., Barber, J. P., Thase, M. E., Perkins, P., & Leon, W. (2011). A quality based review of randomized controlled trials of psychodynamic psychotherapy. American Journal of Psychiatry, 168,

13 References & Bibliography Hart, S. L., Vella, L. & Mohr, D. C. (2008). Relationships among depressive symptoms, benefit finding, optimism, and positive affect in multiple sclerosis patients after psychotherapy for depression. Health Psychology, 27, Howard, I., Turner, R., Olkin, R., & Mohr, D.C. (2006). Therapeutic alliance mediates the relationship between interpersonal problems and depression outcome in a cohort of multiple sclerosis patients. Journal of Clinical Psychology, 62, Hunter, J. J., Maunder, R. G., Gupta, M. (2007). Teaching consultation liaison psychotherapy: assessment of adaptation to medical and surgical illness. Academic Psychiatry, 31, Hinshelwood, R.D. (2004). Clinical Klein: From Theory to Practice. London: Basic Books. Jelliffe, S. E. (1921). Multiple sclerosis and psychoanalysis. American Journal of Medical Sciences, 161, References & Bibliography Kohut, H. (1984). How Does Psychoanalysis Cure? Chicago, IL: Chicago University Press. Langenmayr, A. & Schottes, N. (2000). Psychotherapy with multiple sclerosis patients. Psychological Reports, 86, Lazar, S. (2010). Psychotherapy is Worth It; A Comprehensive Review of Cost Effectiveness. American Psychiatric Publishing. Leichsenring, F. & Rabung, S. (2008). Effectiveness of long term psychodynamic psychotherapy. Journal of the American Medical Association, 13, McWilliams, N. (2004). Psychoanalytic Psychotherapy. New York, NY: Guilford Press. McWilliams, N. (1999). Psychoanalytic Case Formulation. New York, NY: Guilford Press. McWilliams, N. (1994). Psychoanalytic Diagnosis. New York, NY: Guilford Press. Mitchell, S. A. & Black, M. J. (1995). Freud and Beyond. New York, NY: Basic Books. 13

14 References & Bibliography Moos, R. N., & Schaefer, J. (1989). The crisis of physical illness. An overview and conceptual approach. In R. N. Moos (Ed.), Coping with physical illness. 2: New perspectives (pp. 3 25). New York: Plenum Press. PDM Task Force. (2006). Psychodynamic Diagnostic Manual. Silver Spring, MD: Alliance of Psychoanalytic Organizations. Renik, O. (2006). Practical Psychoanalysis for Therapists and Patients. New York, NY: Other Press. Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. American Psychologist, 65, Slavin Mulford, J. & Hilsenroth, M. J. (2012). Evidence based psychodynamic treatments for anxiety disorders: a review. Current Clinical Psychiatry, Sperry, L. (2005). Case conceptualization: A strategy for incorporating individual, couple and family dynamics in the treatment process. The American Journal of Family Therapy, 33, References & Bibliography Sullivan, H. S. (1954). The Psychiatric Interview. New York, NY: W.W. Norton. Sullivan, H. S. (1947). Conceptions of Modern Psychiatry. Washington D.C.: William A. White Psychiatric Foundation. Summers, R., Barber, J. (2009). Psychodynamic Psychotherapy: A Guide to Evidence Based Practice. New York, NY: The Guilford Press. Tolin, D. G. (2010). Is cognitive behavioral therapy more effective than other therapies? A meta analytic review. Clinical Psychology Review, 30, Town, J. M., Diener, M. J., Abbass, A., Leichsenring, F. Driessen, E., & Rabung, S. (2012). A meta analysis of psychodynamic psychotherapy outcomes: evaluating the effects of research specific procedures. Psychotherapy, 49, Wallace, L. (1975). Observations on the psychoanalytic treatment of a patient with multiple sclerosis. International Review of Psycho Analysis, 2,

15 References & Bibliography Watzke, B., Ruddel, H., Jurgensen, R., Koch, U., Kriston, L., et al. (2012). Longer term outcome of cognitive behavioral and psychodynamic psychotherapy in routine mental health care: randomised controlled trial. Behavior Research and Therapy, 50, Weston, D., Novotny, C. M., Thompson Brenner, H. (2004). The empirical status of empirically supported psychotherapies: Assumptions, findings, and reporting in controlled clinical trials. Psychological Bulletin, 130,