Ethical problems of approaching a patient with psychic crisis Mgr. Milo

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Ethical problems of approaching a patient with
psychic crisisMgr. Miloš MauerDep. of Ethics,
3.LF UK Prague

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Psychic crisis - definition

• 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
• Doesnt 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).

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Acute stress disorder (ICD 10)

• 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.
  

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Psychic crisis

• 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 didnt 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.

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Posttraumatic growth

• 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
  wouldnt 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 ones 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.

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Typology of crisis

• 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

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Cause and trigger of crisis

• 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.

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Crisis intervention

• 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).

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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

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Working with resources of patient, strenghtening
of competence and psychic integrity

• - family, partner, friends, community
• - material background
• - life experiences, memories
• - cultural background, faith, values
• - ability of interpersonal contact
• - ability to perceive and communicate ones
  feelings and emotions
• - experiences of personal strength and competence
  under heavy stress

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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).

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Specific stress reactions

• Basic emotions
• 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
• Anxiety, agitation, hyperactivity, panic
• Dissociation, suppresion, derealization,
  depersonalization
• Somatization
• Regression
• Freezing, reactive depression
• Quantitative or qualitative changes of
  consciousness
• Suicidal tendencies

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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

• 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.
• 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).

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Ethical problems of approaching patient in
psychic crisis II

• 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.).
• 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.

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Emotions in medicine

• 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 CR 2009, Kvalita
  ocima pacientu, 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).

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Transitory/developmental crisisCultural
background rites of passage (A. van Gennep,
1960)

• 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.

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Rites of passage - examples

• 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.

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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

• 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.

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Example of posttraumatic growth

• 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."

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