Click Here to View: Powerpoint from James Strain’s Presentation at Symposium 2011: Our Practice Today: Treatment and Transformation at Mt. Sinai Medical Center in NYC on March 5 and 6.
Introduction to James Strain’s presentation:
PSYCHOLOGICAL CARE OF THE MEDICALLY ILL AND DYING:
TREATMENT AND TRANSFORMATION
James J. Strain, MD
Mount Sinai School of Medicine
New York, New York
Psychoanalysis’ conceptual framework has offered important contributions to the psychological care of the medically ill and dying. This paper will discuss:
1. Basic universal stresses
2. Unconscious forces in the physician
3. Counterphobic responses in the physicians.
The Basic Universal Stresses
The sick, hospitalized, dying patient is vulnerable to nine major stresses to which they must adapt to cope with the trials they face (Strain and Grossman 1975):
1. Basic threat to narcissistic integrity.
2. Fear of strangers.
3. Separation anxiety.
4. Fear of loss of love and approval.
5. Fear of the loss of control of developmentally achieved functions, (e.g., bowel and bladder control, regulation and appropriate modulation of feeling states).
6. Fear of loss of or injury to body parts (castration anxiety).
7. Reactivation of feelings of guilt and shame, accompanying fears of retaliation for previous transgressions.
8. Fear of pain.
9. Fear of death and annihilation.
These stresses mimic the stresses that the human experiences in his/her development from birth, latency, adult and elder life. It is how well the individual has mastered these stresses in their development that often predicts their resilience to them in facing illness, hospitalization, and/or death. They also offer clues to the kind of intervention that can be made to assist adaptation if the care taker knows what their patient is struggling with. It is also worth noting that the physician and nurses have also had to master these stresses in their own individual development and their management in themselves and their patients in part depends on the success they achieved in so doing.
A variety of defenses are enacted by the patient to overcome these universal stresses that may have a negative impact on their management of their illness and/or approaching death, e.g., denial; passivity; projection; avoidance, fleeing procedures, thoughts and feelings, etc. And, the physician may have trouble making rounds or talking with a patient whom they are not able to cure or forestall death.
The prerequisites for successful adaptation to illness, hospitalization and death include (Strain and Grossman 1975):
1. Ability to regress adequately in the service of recovery or dying.
2. Ability to maintain adequate defenses against the stresses evoked by illness, hospitalization, and impending death.
3. Access to feelings and fantasies and ability to communicate needs.
4. Basic trust in medical caretakers.
5. Services of empathetic and flexible physicians and caretakers.
The Physician’s Response to the Dying Patient (Spikes and Holland, 1975)
The physician has unconscious fantasies of Omnipotence:
The powerful healer – The corollary to this fantasy when the patient is sick and not responding or dying is to become angry with the patient, wishing the patient would die, or overtreatment when the clinical situation dictates that more treatment is futile, and the patient should be let go.
The destructive force – Just as the physician can be a powerful healer he/she can also be with all that power, a destructive force. This can be manifested by the physician inappropriately and prematurely giving up so as to not “hurt” the patient. Another reaction is to inappropriately transfer the patient rather than have to face his destructive wishes. And, finally the physician may project his disappointments on to the psychiatric consultant, who also cannot help the patient recover. The psychiatrist may as a result become inappropriately angry or enact unwarranted acceptance of the total emotional care of the patient, “relieving” the doctor of any emotional obligation to his patient, thus aiding and abetting psychological abandonment by the primary care taker.
Conclusion
Understanding the universal stresses offers a template for psychological management of the medically ill and dying patient. It also offers a core curriculum for teaching students, family, caretakers, nurses, and physicians how to approach and assist patients to adapt to the exigencies of illness and death.
Reference
Strain JJ, Grossman S: Psychological Reactions to Medical Illness and Hospitalization. In Strain JJ and Grossman S: Psychological Care of the Medically Ill: A Primer in Liaison Psychiatry. Pp 23-36, Appleton-Century-Crofts – Prentice-Hall, New York 1975.
Spike J and Holland JCB: The Physician’s Response to the Dying Patient. In Strain JJ and Grossman S, Editors Psychological Care of the Medically Ill: A Primer in Liaison Psychiatry. Pp 138-148, Appleton-Century-Crofts – Prentice-Hall, New York 1975.