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."

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 well-being.”

“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 goingtowards a solution.

Recognition that solution needsto involve primary care.

Recognition that the metal health system and medicalsystem 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 systemNo insuranceManaged CareStigma CompetitionLagging 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

BASED ON THE WORK OF SILVAN S. TOMKINS AND DONALD NATHANSON, M.D.BRIAN LYNCH, M.D.

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 homesPrecepting medical studentsTeaching 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.