Post on 27-May-2018
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Multiple Sclerosisand Psychodynamic
Case Conceptualization
A. Elizabeth Hirky, Ph.D.Adjunct Assistant Professor
Ferkauf Graduate School of PsychologyYeshiva University, Bronx, NY
Consortium of Multiple Sclerosis CentersDallas, Texas ‐May 29, 2014
Question: % Time Conducting Formal Psychotherapy/Interventions
1. 0 – 25%
2. 26 – 50%
3. 41 – 75%
4. 76 – 100%
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Question: % Time InformalCounseling/Support
1. 0 – 25%
2. 26 – 50%
3. 41 – 75%
4. 76 – 100%
Question: Which Best Characterizes Your Psychotherapeutic Orientation?
1. Psychodynamic/psychoanalytic
2. Cognitive‐Behavioral
3. Integrated or “Eclectic”
4. Family Systems
5. Other
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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
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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?
• > 500
• 200 – 499
• 100 – 199
• 50 – 99
• 20 – 49
• < 20
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Psychodynamic Literature & M.S.
• e.g.: Jelliffe, S. E. (1921). Multiple sclerosis and psychoanalysis. American Journal of Medical Sciences, 161(5):666‐676.
• 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, 82:374‐400.
• Leichsenring, F. & Rabung, S. (2008). Effectiveness of long‐term psychodynamic psychotherapy, JAMA, 13:1551‐1565.
• 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, 98‐109.
• Summers, R., Barber, J. (2009). Psychodynamic Psychotherapy: A Guide to Evidence Based Practice. New York, NY: Guilford Press.
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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)
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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)
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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.“
http://www.apsa.org/About_Psychoanalysis.aspx
• Type of treatment
• Theory of the mind
• 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, 2nd Edition, Eells, T. D., Editor. New York, NY: Guilford Press.
Resources for Psychodynamic Theory & Case Conceptualization
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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)
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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)
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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 2007
• 4 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
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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, 137‐156.
• 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, 374‐400.
• 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, 19‐28.
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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, 230‐238.
• 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, 1197‐1204.
• Hunter, J. J., Maunder, R. G., Gupta, M. (2007). Teaching consultation‐liaison psychotherapy: assessment of adaptation to medical and surgical illness. Academic Psychiatry, 31, 367–374.
• 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, 666‐676.
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, 495‐508.
• 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, 1551‐1565.
• 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.
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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, 98‐109.
• Slavin‐Mulford, J. & Hilsenroth, M. J. (2012). Evidence‐based psychodynamic treatments for anxiety disorders: a review. Current Clinical Psychiatry, 117‐137.
• 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, 353‐364.
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, 710‐720.
• 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, 276‐290.
• Wallace, L. (1975). Observations on the psychoanalytic treatment of a patient with multiple sclerosis. International Review of Psycho‐Analysis, 2, 65‐77.
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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, 580‐587.
• 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, 631‐663.