General Overview of mental health

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MIND - AFFECT - BODY AFFECT AND SCRIPT IN
MEDICINE
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AFFECTS
INTEREST
JOY
SURPRISE
ANGER
FEAR
DISGUST
DISTRESS
DISSMELL
SHAME
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INTEREST
WITHDRAW
SHAME
ATTACK SELF
ATTACK OTHER
AVOID
NEGATIVE
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General Overview
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GOAL Integrate affect into general clinical
medicine. Particularly Primary Care
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What are the impediments? How can we overcome
them? How have I tried to overcome Obstacles?
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Overview of present environment.
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Medical and economic milieu and attendant
impediments. To change the system seems
overwhelming.
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But there is growing recognition of the
importance of unifying mind and body.
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At least since 1946 we havetried to officially
recognize the link between mind and body as
exemplified by
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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."
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Or as I often present it to people,and taking
it a step further,AT is about normal physiology
and psychology
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There is really no abnormal. The organism is
always responding the best it can for the
circumstances.
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But using the disease model we generally
recognize that many diseases have a mind-body
connection.
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We have always explored the spiritual connection
to health and searched for a Holistic
Medicine.
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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.
17
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.
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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.
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We are in the historical process. Why is the
system not more coherent?
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1999First Surgeon
Generals report on mental health.
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This report recognizes the inextricably
intertwined relationship between our mental
health and our physical health and well-being.
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We recognize that the brain is the integrator of
thought, emotion, behavior, and health..
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the extent to which it has mended the
destructive split betweenmental andphysical
health.
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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.
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IMPEDIMENT Massive Withdrawal
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Individuals should be encouraged to seek help
from any source in which they have confidence.
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"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.
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"Primary health care could be an important portal
of entry for children and adults of all ages
with mental disorders.
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"For the general public, primary care represents
a prime opportunity to obtain mental health
treatment or an appropriate referral.
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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.
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This talk is about placing affect in the
medical model and the attendant problems in
doing this. So a bit more orientation
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Medicine is a huge enterprise. I will talk about
my area. Again Primary Care and particularly
Family Practice.
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What is Primary Care?
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It is usually thought of as Family Practice,
Pediatrics and Internal Medicine. OB-Gyn in
most places are also recognized.
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• 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.

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I often say that we are not really even one
profession any more. I have very little in
common with a cardiovascular surgeon.
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Only the still present GP and Family Practitioner
are really at all equipped as a group to see
the patient in their entirety.
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Mental Health Where does it fit in medicine?
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First of all care is fragmented as we all know.
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Settings Private therapy Marginalized care
County-State MH Dept. Medical Practice
50 psychiatry Family Practice
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We have a world of DSM and Tomkins
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And of course no one knows about Tomkins.
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This, of course, is no small problem.
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On the other hand there is really nothing
unifying out there.
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Look at BOL the Internet site.The Behavioral
Science in Primary Care site has very poor
participation as does Ethics, Law and
Psychotherapy.
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SoRecognition of mind-body problem.Recognitio
n that we are goingtowards a solution.Recogniti
on that solution needsto involve primary
care.Recognition that the metal health system
and medicalsystem are fragmented.
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Basics of medical education
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MEDICAL SCHOOL Major mental disorders.
Biological model.
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RESIDENCYMost have no contact or exposure
except grand rounds.Or you are exposed to only
severe mental health problems that scares you
away.
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MANAGED CAREMajor 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.
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Or if they find out you will do it they will
send patients to you instead of the
psychiatrist and pay you less.
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These are real problems. Some areas have
upwards of 80 per cent managed care
penetration. Not all providers can ignore them.
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Public perception The quick fix problem that does
indeed exist. People do have busy lives and do
feel they cant slow down to get help.
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Stigma Shame Resistance to medication Confusion
about how to enter system
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Able to tolerate physical diagnosis rather
then being crazy.
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Nurse Practitionersand huge number ofpeople
coming in asentrepreneurs with no medical
background.
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Medication as an impediment.
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Not sure why therapists want prescription
privileges!.
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Job Offer
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So again mpediments are manyOverall systemNo
insuranceManaged CareStigma CompetitionLagging
educational system
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ROOTS
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Deep historical and philosophical reasons. For
where we are.
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To really address these issue we would have to
look at much deeper into Western thought at
least going back to the Greeks.
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Descartes, modern and post modern thought. All
of it caught pretty much up with reason. -Little
about emotion.
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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.
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Descartes He wanted to purge reason of the
passions. Thing is he admitted he couldnt yet
we continued thinking he did as The Algebra and
Calculus where and are so powerful.
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Isnt it true that when we first
introduce people to AT they will object that
when we do math we do it with pure reason.
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So we all know there are great cognitive
castles built up that are great impediments.
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Overcoming Impediments
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Again what can we say about physical problems
being connected to the mind?
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More specifically what do we know about the
mind body connection.?
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Leading causes of death have strong affective
links.
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CHOLESTEROL, OBESTIY,SUICIDE, DRUG ABUSE,
ANGINA, HYPERTENSION, CHIRROHSIS, TRUAMA
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All of these have at least a major emotional
and cultural component.
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Attack self scripting Study showed huge
percentage of patients doing something to
sabotage care.
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WITHDRAW
ATTACK OTHER
ATTACK SELF
AVOID
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The blue area represents where I think most
medical patients fall.
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The red area represents where I think most
physicians fall.
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Solutions?
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Lets look at an example of specialty care
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Dr. Lance Gould in Huston
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Use of IMAGE via PET SCANS
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Patients are highly motivated.
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Image plus, drugs, diet (Dean Ornish)
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They admit that patients are motivated.
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They recognize that it is time intensive and
notreimbursed.
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The missing link is how do we motivate those
that are not, the ones that are passive?
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I think by first teaching about affect.
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What do I do?
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My job is different from the regular therapist.
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Simply someone can come to me for anything.
But everything has an affective component.
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Although I do traditional therapy.
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For the medial patient initially they have no
idea of the role of affect or it is hidden just
under the surface.
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Patient comes in with a boxers fracture of
the right hand.
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He hit a wall and broke is hand.I took 20
minutes giving himsome idea of what was
reallygoing on.Did I do any good?
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So how do I bring it up?.
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If you go looking you will find an affect
problem almost always.
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This is Family Practice
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What defines Family Practice?
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We might say affect.
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We are on the front line. The history is almost
always affectively charged. People are fighting
fear. Always minimizing.
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But what do I do?
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I write down the nine words.
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AFFECTS
INTEREST
JOY
SURPRISE
ANGER
FEAR
DISGUST
DISTRESS
DISSMELL
SHAME
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I ask if any of them are bothering them.
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AFFECT CHART
RATE SELF FROM 1-10 AND INDENTIFY IF 'TRIGGER'
IS INTERNAL OR EXTERNAL.
SUNDAY
MONDAY
TUESDAY
WED.
THURS
FRIDAY
SATURDAY
INTEREST
JOY
SURPRISE
ANGER
DISGUST
FEAR
DISTRESS
DISSMELL
SHAME
BASED ON THE WORK OF SILVAN S. TOMKINS AND DONALD
NATHANSON BRIAN LYNCH,M.D.
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I go through the Compass Of Shame
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INTEREST
CONFUSION
WITHDRAW
NEGATIVE
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INTEREST
CONFUSION
WITHDRAW
NEGATIVE
ATTACK SELF
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INTEREST
CONFUSION
WITHDRAW
NEGATIVE
ATTACK SELF
AVOID
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INTEREST
CONFUSION
WITHDRAW
NEGATIVE
ATTACK SELF
ATTACK OTHER
AVOID
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INTEREST
CONFUSION
WITHDRAW
NEGATIVE
ATTACK SELF
ATTACK OTHER
AVOID
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INTEREST
CONFUSION
WITHDRAW
NEGATIVE
ATTACK SELF
ATTACK OTHER
AVOID
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INTEREST
CONFUSION
WITHDRAW
NEGATIVE
GUILT
ATTACK SELF
ATTACK OTHER
AVOID
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INTEREST
INTEREST
CONFUSION
WITHDRAW
NEGATIVE
GUILT
ATTACK SELF
ATTACK OTHER
AVOID
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DEFINE
INTEREST
INTEREST
CONFUSION
WITHDRAW
NEGATIVE
GUILT
ATTACK SELF
ATTACK OTHER
AVOID
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DEFINE
INTEREST
EVALUATE
INTEREST
CONFUSION
WITHDRAW
NEGATIVE
GUILT
ATTACK SELF
ATTACK OTHER
AVOID
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DEFINE
INTEREST
EVALUATE
MODERATE
INTEREST
CONFUSION
WITHDRAW
NEGATIVE
GUILT
ATTACK SELF
ATTACK OTHER
AVOID
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DEFINE
INTEREST
EVALUATE
CONTROL
MODERATE
INTEREST
CONFUSION
WITHDRAW
NEGATIVE
GUILT
ATTACK SELF
ATTACK OTHER
AVOID
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DEFINE
INTEREST
PRIDE
EVALUATE
CONTROL
MODERATE
INTEREST
CONFUSION
WITHDRAW
NEGATIVE
GUILT
ATTACK SELF
ATTACK OTHER
AVOID
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Then I see what happens.
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I will usually spend at least an hour and try
to get them back soon for the second hour.
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HOME WORK
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AFFECT CHART
WHAT CASUSES THE AFFCET?
WHAT DO YOU DO WHEN YOU FEEL THIS AFFECT?
NOTES
INTEREST
JOY
SURPRISE
ANGER
DISGUST
FEAR
DISTRESS
DISSMELL
SHAME
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The medical problem often drops into the
background but it is not ignored.
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40 YO MALE MODEREATELY SEVERE EMPHYSEMA CARES
FOR MOTHER
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ANGER DESTRESS INDENTIFIED
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GONING ABOUT OUR BUISNESS
CONFUSION
INTEREST
OBLIGATIONS --gt DISTRESS
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WE FEEL SOMETHING
WE DO SOMETHING
INCREASED O2 DEMAND
FATIGUE
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MONITORS THESE WELL VERY STABLE OVER LAST YEAR
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42 YO MALE MIGRINES DAILY INTENSE SLEEP
DISTRUBANCE HEORINE USERE
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TWO HOURS OF DIATATIC TEACHING INDENTIFIED
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ANGER FEAR AT '10'
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OVER LAST YEAR HAS RELAPSED BUT GOT
JOB MIGRAINES SUBSIDED SLEEP MEDCATION DECREASED
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HAS QUIT AGAIN AND MANAGED NEW SEVERE
TRAGEDY WITH MORE SKILL
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55 YO FEMALE 8 YEAR HISTORY CRYPTOGENIC CHIRROS
IS
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HAS SHUNT RECENTLY MULTIPLE HOSPITALIZATIONS
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WHAT AFFECT?
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ANGER AT '10'
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38 YO MALE NEW ONSET DIABETES
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HIGHLY EDUCATED VERY SLOW IN ACCEPTING DIAGNOS
IS
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GONING ABOUT OUR BUISNESS
CONFUSION
INTEREST
DIABETES (ANY NEW DIAGNOSIS)
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32 YO FEMALE AIDS RECENTLY MARRIED
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RECENTLY MARRIED NEW BORN HUSBAND 'ATTACKING'
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SEVERAL SESSIONS INDENTIFYING AFFECT
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PRODUCES DRAMATIC CHANGE IN RELATIONSHIP.
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32 YO WOMAN IN DIFFICULT MARRIAGE FIBROMYALGI
A LONG TERM INTENSE RX
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FIBROMYLAGIA SUBSIDES RETURNS LESS AND LESS
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Major impediment is our own shame due to
ignorance.
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WE ARE DISTRESSED WHEN WE SEE AN
OVERWEIGHT PATIENT.
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KOWNING YOURSELF ALLOWS YOU TO EMPATHIZE. TO
KNOW YOUR PATIENT.
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JOSE AND HYPERTENSON
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treatment. They can in fact kill us.
 
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W.T.
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V.B.
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N.B.
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BACK PAIN
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IBS
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MIGRAINE
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FIBROMYLAGIA
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So unlike traditional therapy which is limited
to a fairly well defined contract for
services..
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Medicine is not the same.I see what I am doing
then as Model for applying AT to the larger
world .
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And within medicine I have had the privilege of
apply AT in various settings..
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Traditional doctor patient visit.Group therapy
Sheltered workshops Schizophrenic
shelters Nursing homesPrecepting medical
studentsTeaching Medical Ethics Substance
abuse Groups Hospital detox
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Summary
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Western culture can be see as a long history of
separating mind and body. .
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All our institutions reflect this fact.
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Now there are many that would like to solve
this dualism as exemplified by the WHO
statement on health and the Surgeons
Generals report.
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Many impediments Financing Consumerism
Continued stigma of having mental
problems Again our history reflected in
physician education. The role of
medication Surgeons Generals report.
Infighting and truf battles
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But many are trying creative ways of unifying
mind bodySuch as Dr. Gould in Huston
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But Tomkins does it better. Impediment
Few know of him.
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At least I think I have shown that it can be
integrated into medicine and that it works.
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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. Nathansons school program where, as he says,
we can immunize children.
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DEFINE
INTEREST
PRIDE
EVALUATE
CONTROL
MODERATE
INTEREST
SHAME
NEGATIVE
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