11 Psychological Phenomenon that Arise in Patient Care

Question 1

Sigmund Freud

Answer 1

Doctor at University of Vienna in 1881

• Researched cerebral palsy, aphasia, and microscopic neuroanatomy
• Lectured in neuropathology
• Created psychosexual theory of development postulating that personality is mostly established by age 5

Question 2

Freud’s Structural Model of the Psyche

Answer 2

Composed of 3 components:

• Id
• Ego
• Superego

Question 3

Id

Answer 3

biological urges, instincts

maximizes pleasure; acts according to pleasure principle

Question 4

Ego

Answer 4

realistic thinking

postpone pleasure until appropriate

mediates between desires of id and superego; acts according to reality principle

Question 5

Superego

Answer 5

values, conscience ego-ideal

how the ego should behave

Question 6

Psychological Defense Mechanisms

Answer 6

Unconscious ways by which the ego wards of anxiety and controls unacceptable instinctual urges and unpleasant affects or emotions by manipulating, distorting, or denying reality

The purpose of defense mechanisms is to protect the mind/self/ego from anxiety and/or social sanctions and/or to provide a refuge from a situation with which one cannot currently cope

• A defense mechanism becomes pathological only when its persistent use leads to maladaptive behavior such that the physical or mental health of the individual is adversely affected.

Question 7

Denial

Answer 7

Primitive defense to avoid pain or anxiety, prevents recognition of external reality

• Reality is refused in favor of internally generated, wish-fulfilling fantasies
• Commonly seen in general medical practice
  
  • denial of test results
  • avoiding medical care

Question 8

Projection

Answer 8

falsely attributing to someone else your own unacceptable feelings, impulses, or thoughts

• Plays a role in prejudicial attitudes: bigots project attributes that they disavow in themselves (lazy, cheap, dirty, immoral, etc)

Question 9

Regression

Answer 9

Pts escape anxiety by returning to earlier level of adjustment during which gratification was ensured

• Person returns to an earlier stage of development and to more childish and childlike forms of behavior
• Common response to severe chronic illness and to hospitalization
  
  • Patients make insatiable demands, complain insistently, demand medication, request special privileges,

Question 10

Identification

Answer 10

some traits or attributes of another person are taken as your own

Example

• Attending physician mistreats resident, who in turn is abusive toward medical students

Question 11

Repression

Answer 11

• Memories, feelings, and drives associated with painful and unacceptable impulses are excluded from consciousness
• Struggle with internal stimuli

Question 12

Reaction Formation

Answer 12

thoughts, feelings, or behaviors that are opposite to your own unacceptable thoughts or feelings

• Person who is unconsciously very needy lives a life of exaggerated independence
• Person who is unconsciously very needy lives a life of exaggerated independence

Question 13

Isolation of Affect

Answer 13

One deals with emotional conflict, internal or external stresses by the separation of ideas from the feelings originally associated with them

• The emotional component of an idea is repressed while the cognitive component remains conscious

Question 14

Intellectualization

Answer 14

(socisism)

• Shift of emphasis from immediate interpersonal conflict to abstract ideas and esoteric topics
• Think about wishes in bland terms to avoid experiencing strong emotions

Question 15

Displacement

Answer 15

• redirecting an emotion from its original object to a more acceptable substitute
  
  • Most commonly involves anger
    
    • anger at work directed towards pts family

Question 16

Undoing

Answer 16

Say or do something to negate or symbolically make amends for unacceptable thoughts, feelings, or actions

Example:

• Neglectful parent showers presents on his/her children

Question 17

Sublimation

Answer 17

Divert unacceptable drives into socially acceptable channels

• A person experiencing extreme anger takes up kick-boxing

Question 18

Altruism

Answer 18

Adaptive defense mechanism against feelings of inferiority, lack of fulfillment

• Helps alleviate feelings of emotional isolation, lack of significance
  
  • (voulneteering)

Question 19

Suppression

Answer 19

nConscious decision to postpone paying attention to an unpleasant subject, impulse or conflict

Only conscious defense mechanism

Example: college student comes home from school and finds many bills that need paid in the mail. The student consciously ignores the bills until after she has studied for the next day’s exam.

Question 20

Humor

Answer 20

Unconscious or forbidden feelings are expressed via a socially acceptable outlet

• Making a joke in an effort to lighten and defuse a tense or sad situation
• self-deprecating humor

Question 21

Adaptability of Defense Mechanisms

(The psychiatrist George Eman Valliant introduced a four-level classification of defense mechanisms based on their effectiveness)

List all 4

Answer 21

1. Level I - pathological defenses (psychotic denial, delusional projection)
2. Level II - immature defenses (fantasy, projection, passive aggression, acting out)
3. Level III - neurotic defenses (intellectualization, reaction formation, dissociation, displacement, repression)
4. Level IV - mature defenses (humor, sublimation, suppression, altruism, anticipation)

Question 22

Transference

Answer 22

People view one another through distorted lenses that have to do with past experience and early encounters

• Patient “transfers” feelings toward others in their life onto the physician
• Example: If patient has grown up perceiving others as unhelpful or even harmful, he/she will likely view the physician the same way

Question 23

Countertransference

Answer 23

Physician transfers feelings toward others in their life on to the patient

Question 24

Ambivalence

Answer 24

“I want to and I don’t want to”

People often feel two ways about behavioral change. They weighing the discomfort/disruption of changing their behavior (short term) with their hope for desirable outcomes (long term)

• Empathic, non confrontational styles can facilitate change
• Controlling, confrontational styles can make patients regress and become resistant to change.

Question 25

5 Strategies for Managing Ambivalence

Answer 25

1. Express empathy through listening, not telling
2. Identify discrepancies between where patient is now, and where he/she wants to be
3. Avoid arguing (trying to convince/persuade)
4. Roll with resistance, don’t challenge it head on
5. Support self-efficacy, instill hope, encourage person’s belief he/she can change

Question 26

Change Talk

Answer 26

A tool used by providers to communicate in a way that gets the invididual to list the reasons why they should change their behavior

Four Categories of Change Talk

1. Disadvantage of the status quo
2. Advantages of change
3. Optimism for change
4. Intention to change

Question 27

Patient Shame

Answer 27

Patients are at high risk for experiencing shame and humiliation in medical encounters. They commonly perceive diseases as defects, inadequacies, or shortcomings. Their health behaviors may be attributed to weakness, stupidity, immorality, or personal failure.

• physically manifest in blushing, sweating, burning, freezing, fainting, sense of weakness
• Common responses to shame: anxious laughter, withdrawal, avoiding the physician, withholding information complaining, suing

Question 28

How can doctors avoid pt shame?

Answer 28

• Minimize delays
• Refer to patients by proper titles and last names
• Support patients’ identity
• Be mindful of privacy
• Self-disclose when possible and appropriate
• Avoid using shame and humiliation as motivational tools
• provide empathy for physiological manifestations of shame
• Validate/praise the patient for seeking help managing disease
• Inquire about patient’s attributions, clarify misconceptions
• Recommend support groups
• Establish the patient’s goals/concerns; don’t force your agenda
• Be mindful of your emotional reactions

Question 29

Validation

Answer 29

Informs a person that you understand the reason for his/her emotion

Question 30

Function of Emotions

Answer 30

Emotions have a purpose

–Prepare us for action

–Communicate to others

–Communicate to ourselves

– Emotions serve an evolutionary function

Fear, Anger, Shame, Guilt 

– It is difficult to change or stop feeling emotions until their function is served

Question 31

Levels of Validation

Answer 31

1. Listening, paying attention
2. Reflecting, acknowledging the other’s points nWorking to understand; asking questions, making hypotheses Understanding problems in context
3. Normalizing responses when they are normative
   
   1. (its ok to feel how you feel)
4. Extending, matching with your own vulnerability

Question 32

Invalidation

Answer 32

issuing a command to a pt demanding that their behavior change without letting the emotion run its course

• Warning/threatening: without understanding the context of what is happening
• Evading/missing/avoiding the point: focusing on own point of view instead of pts
• using logic/lecturing/argument about why behavior should change
• telling pts what they should/ought to think, feel, do
• validating the invalid by reassuring / sympathizing / consoling that an emotion will be ok when its not