Psychotherapeutic intervention in acute medical situations

PsychotherapeuticInterventionin Acute Medical Situations Chase Patterson Kimball, M.D. Professor of Psychiatry and Medicine Division of Biological Sciences and in the College, University of Chicago, Chicago, Illinois

Abstract: Psychotherapy in the extreme medical situation is an extension ofthe interviewing process. The interviewer must expeditiously and sometimes briefly assist the patient in elaborating his complaint, obtain information about the development of the complaint, and assess the patient’s reactions to it. Past history, developmental patterns, reactions to previous illness and crises, the patient’s present life situation, and past and present relationships may all be relevant and require evaluation. Theinteractiveprocess requires that the therapist call upon specific knowledge as he engages with the patient, facilitates the expression of concern, appropriately reassures, instructs, and prepares, clarifies, and leads the patient to some insight about his altered state. Attention to the affective correlates of acute illness can enhance convalescence and the rehabilitative process.

Definitions In discussing psychotherapeutic processes in patients in the acute phases of illness, it is first necessary to identify the territories to be explored. The acute situation can be defined as inclusive of the period of time and the place in which the patient becomes ill and is taken for treatment and diagnosis: The time may include the critical state in which there is question about survival and the immediate convalescent period; the place may be a clinic, emergency room, or hospital ward. This acute or critical state is often experienced as if one were in a foreign culture, in different and usually unfamiliar environments and among strangers. The individual in the acute situation is isolated from

Presented at the Fourth Congress of the International College of Psychosomatic Medicine, Kyoto, Japan, September 8, 1977.

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familiar contacts such as family and is exposed to the difficulties of adjusting to the emotional reactions of others. Therapy is defined in a relatively broad sense, focusing on what transpires in the relationship between the patient and the many individuals attending the patient, including diagnostic as well as therapeutic procedures. Psychotherapy is discussed in the narrower sense of specific techniques utilized by a psychiatrist or communicated by him to other individuals attending the patient.

The Liaison Consultant A common denominator and multiple extrapolation may be developed from different illness situations; but the liaison psychiatrist must also have specific knowledge about specific illness situations to be optimally effective as a therapist. The focus in this discussion is on the patient with cardiovascular disease, based on the experience of investigations of patients sustaining myocardial infarctions and those undergoing cardiovascular surgery (1, 2). The fundamental knowledge for implementation of any therapy comes from the patient. The knowledge that we have of psychotherapy is based on experience with approaches and processes. Psychotherapeutic skill comes from practice and innate ability. The knowledge of situations and specific illnesses serves as a framework to orient the physician to the form or dimensions that an experience with a specific patient may take. Because knowledge of the patient is derived from talking with the patient, psychotherapy also commences at this time. The demonstration of an effective interview technique by the liaison consultant to primary care perGeneral Hospital Psychiatry @ Elsevier North Holland, Inc., 1979

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sonnel will enhance a psychotherapeutic orientation to the patient from the time of his initial contact with the health services (3).

The Patient Because the consultant meets the patient somewhere along the spectrum of illness after the acute process has begun-sometime in the course of the relationship with the patient or in supervision of others in this work-the consultant will need to relive with the patient these early moments: How did he first become aware of the symptom(s)? When? Where was he? With whom? What did he experience? What did he feel? What did he do? begins to Through this process, the consultant understand how this individual reacts to catasand trophic events, how he copes emotionally, how he utilizes defenses and reasoning powers. He also learns about the patient’s orienting and arousal states. This stands the consultant in good stead in his future work. At the same time, he has accomplished a primary aspect of therapy, that is, getting the patient to talk about himself and especially about his feelings. In the dependent state, the patient is also more able to talk about how he behaved and how he has coped actively with his problem in the past and has the ability to cope similarly now. In this preliminary exploration, the consultant has picked up much factual information that will assist him in identifying specifics about the patient and his illness. He has been able to assess his patient’s present feeling state, his defenses and their effectiveness and limitations, and his specific coping activities. The therapist has also obtained a good description of the symptoms and their progress and of what the patient was doing, with whom, and what other events were occurring in the proximal onset situation. He will also have gleaned a bit of data about the patient’s recent past in terms of marital, social, and work activities. He will have identified not only the symptom-pain, dyspnea, fever, cough, and so on-but also the patient’s tolerance for this, as well as his fears and present rationalizations.

Anxiety In the immediate present, whether in the emergency room or the intensive care unit, the patient and the therapist are in a similar situation. They are both dangling on the thread of a decision regarding the pathophysiologic process, in which the prevail-

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ing emotion is anxiety (4). It will persist until something definite has occurred. The anxiety relates to the present, i.e., what is-the pain, the strange environment, the diagnostic procedures, including the interview; the future, i.e., what could be-the heart attack, the embolism, cancer, pneumonia; and the possible consequences-death, invalidism, deformity, loss of status. Previous investigations suggest that throughout the acute phase of illness, the patient is more concerned about his discomfort (the pain of living) than about death. Concern about dying and death is a luxury that is afforded when other feelings are less acute. This occurs later on. Much of the anxiety experienced from outside the body relates to the environment, which is a strange and changing one in the acute situation. The environment begins to change at the time of symptom onset. Depending on the physiologic changes, there may be perceptual distortions in feelings about the body, or of the pain in vision, hearing, and tactile sense. These perceptual distortions will influence cognition and may be accompanied by various emotional sensations such as anxiety and specific fears. The patient defends himself against these by a variety of characterologic maneuvers. A common one is the sense of distancing oneself from what is happening and from the environment.

Altered States of Consciousness This is the initial stage of an altered state of consciousness that may progress, wax and wane, or exist ephemerally (5,6). An awareness of this by the therapist will allow him to moderate the extent and intensity of his interaction. It will also stimulate him to seek the source of this alteration-whether it relates to the anxiety about the pain or the environment or to specific pathophysiologic effects of the illness or its treatment with analgesics, hypnotic sedatives, and antianxiety agents. A patient in such a state requires an altered approach in interaction: a structuring one, a limited one, but a frequent one. The patient should not be left alone, especially if he is apprehensive and agitated. Reassurance should be given in simple, direct, and matter-of-fact terms, often best accomplished by aides. They need only emphasize the identity of the patient, where he is, what has occurred, that things will be all right, who the attendant is, and that she is going to stay. Repetition of such details is important. Delusions and hallucinations are usually ego alien and are handled well 151

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by the patient with a bit of reinforcement by the aide or the physician. Identifiable correlates of this state must be remedied. Small amounts of butyrophenones administered orally and frequently over a 3- to $-hour period will often ameliorate agitation, although this is not a replacement for the interaction described above. Once an adequate amount has been determined, dosage is repeated at regular intervals over the next 7-10 days. Recognizing and treating early deficits in the cognitive functions of attention, orientation, and memory as well as increasing emotional liability will help prevent the delusions, hallucinations, and agitation of advanced delirium.

The Environment The initial reaction of anxiety by most patients to the distress of symptoms is exacerbated by the environment in which the patient is attended (7). As noted, these are alien environments, unfamiliar to most patients. They are alien in every sense: sound, sight, touch, smell, taste, and proprioception. Even for the alert, oriented, and well, these alien environments, crowded with patients and personnel, can convey a sense of the unreal and lead to disorientation and depersonalization. Compounding the patient’s anxiety about himself is an aura of anxiety indigenous to these units. Ambulances scream into the unloading docks to which a stream of personnel are mobilized. The instruments of medical progress are mobilized for initial sustenance of life while multiple diagnostic procedures are instituted. The atmosphere is rife with the sounds of monitors, suction machines, patients’ moans, and their families’ lamentations. The loudspeakers signal the harried staff and announce the imminent arrival of new victims of tragedies for whom new forces must be mobilized. The stretcherridden patients wait for first one and then another consultant or technician for what must seem like an eternity. After triage, initial diagnosis, and preliminary treatment, the patient is transferred to a new and equally foreign environment, which causes a new uncertainty and increased anxiety. Most patients, other than cardiovascular surgery patients, have had little experience with an environment such as that of the coronary care unit. In this arena of uncertainty, the individual is often at the threshold between two worlds, that of the painfully living and that of the unknown dead. It is an arena in which resignation is not unknown. The previously inter152

viewed cardiovascular patient has had some preparation for this environment; in many places, he has been exposed to this unit in the preparation for surgery. Such is not, however, the experience of the myocardial infarction patients. There has been no time to identify those patients at greater risk for specific emotional reactions to illness nor for the remedial intervention that specific risk factors might indicate. The anxiety developing in the emergency area continues to mount over the first several days and continues to correlate with the severity of symptoms related to the disease process. Attempts to modify this pharmacologically through analgesics or hypnotics frequently increase the anxiety by leading to greater confusion in this strange environment. During this early experience in the intensive care unit, the combination of high anxiety and unfamiliarity fosters the greater levels of confusion, anxiety, and sense of depersonalization in susceptible individuals. Crucial for the well-being, if not the life, of the patient is attention, first, to the detection of confusion and, second, to reorienting procedures. As the patient moves out of the anxiety phase, where the primary defense is denial, he begins to demonstrate other behaviors that are characteristic of his premorbid patterns in reaction to stress (8). A patient who is usually demanding and plaintivemay demonstrate these behaviors in an exaggerated form. Recognizing that this is based upon anxiety and uncertainty will lead the staff to take time in helping the patient structure his life. Rather than respond to the patient’s demands ad lib, it is helpful to assure the patient that someone, preferably the same individual on each shift, will attend the patient at fixed intervals. Another patient may respond to anxiety with irritability, anger, and hostility, manifested by threatening and menacing behavior; this calls for immediate, matter-of-fact setting of limits by the individual in charge. An individual who is suspicious by nature will become more so during times of acute stress; staff can minimize this by giving precise, clear, and simple statements about what is happening. The obsessive individual will respond to the staff’s recognition of the patient’s concern for precision, detail, and exceptions. If changes are to take place in the patient’s schedule, he should be fully apprised well beforehand and given an explanation. The hysteric, on the other hand, will only become more anxious and concerned with detailedexplanations. Rather, he requires frequent reassurance and simple explanations. Another patient may become almost mute

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and withdrawn; in this case, patient and extended efforts of a staff member to penetrate this defensive style are required. Confrontation techniques may occasionally reduce the resistance of these individuals, although they may antagonize others. During the second phase of the intensive care unit experience, the major affect is one of sadness, sometimes anger at self, sometimes resignation manifested by behavior based upon characteristic defenses. Although self-limited in some, this affect extends well into the convalescent phase in others, and if left unattended, may evolve into or be superceded by a frank depression following convalescence, which accounts for much of the morbidity associated with the postinfarction period (9). Protracted sadness that remains unexplored, unmobilized, and verbally unexpressed may become latent and appear as fatigue, listlessness, helplessness, and hopelessness. At the initial phase, it resembles the “giving up-given up” state with its expressions of helplessness-hopelessness; its verbalization of, “It’s all too much, I can no longer cope”; its physical posture of bowed head, turned-down mouth, and thrown-down palmupward outreached arms and hands; its preoccupation with the past and its tragedies; its failure to identify a future; and its sense of disengagement or retreat from the present and those within it (10). The physiologic characteristics’of this in limbo state may be potentially adaptive or maladaptive for the patient. This state can also be viewed as a conservation withdrawal state that follows the acute stress the patient has thus far survived (11). It is characterized physically by a turning away from staff and family, a reduced appetite, and an increased sleep pattern, and verbally, by a patient saying, “All I want to do is sleep. I’ve been through so much. Now, I just want to turn toward the wall and sleep.” The sleep and fatigue are real. It is estimated that in the acute care units, patients sleep about 4 hours out of 24. In the convalescent units, it is not unusual to observe patients who sleep up to 19 hours per day. Usually, these patterns last 2-5 days. The role of the liaison therapist at this time is to assist in documenting the state and to advise the attending staff, especially physicians and surgeons, to leave the patient alone.

Convalescence The remainder of the convalescent period is devoted to taking stock of what has happened; based

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on this appraisal, preparations and plans for the rehabilitation phase begin. During this period, there are occasional exacerbations and complications of the underlying illness, which will set the patient back, again raise doubts, fears and anxieties, and occasionally lead to resignation, which will require identification and exploration. The first part of the convalescent period allows the therapist to review and bring together the various aspects of self-grieving that the individual has experienced for the real and partial loss of self (12). In this grieving process, the patient is helped to review prior experience and feelings about the illness, with opportunities to vent those feelings and to associate them with similar feelings about various past losses. Dreams, often exacerbated by hypnotic sedatives at this time, are frequently of these past vulnerabilities with their manifest content of the experience. Rather than provoking anxiety, such recollections and reminiscences can bring about resolution and a greater sense of tranquility. This is a time when the past meets the future and the insecurities that the patient has experienced in the past are projected on the future. The concerns are real and must be separated from the overdetermined emotions in which they are invested because of unresolved conflicts of the past.

Group Processes The real concerns about the future may often be bridged effectively and satisfactorily in group processes during the convalescent phase (13). These groups are conducted in the hospital with spouses and sometimes other family members. They may include all or selected members of the therapeutic team. The content is frequently didactic in relation to common problems faced by all: diet, exercise, sexual activity, and medicine. Anticipations and apprehensions common to all spouses are aired in these discussions as a step toward their alleviation. Illness of the individual is also illness in the family, and although therapy for the patient may result in his return to health, it does not guarantee a return to health of the family; illness of the individual causes dysfunctions within the family, which require attention. Adolescents react to the illness of a parent with various behaviors, including anxiety, distrust, withdrawal, alliances outside of the home, defiance, and occasionally self-destructive behavior. Young children, watching the disintegration of 153

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previous stable family patterns, may show regressive behavior and develop symptoms of childhood neurosis: tics, thumb sucking, enuresis, fear of school and other phobias, and sleep disturbances including nightmares. One or more family sessions may result in the release of repressed affects centered around internalized and unresolved conflicts that the illness has aroused. Preparation of both patient and family for the homecoming (14) is an essential component of therapy following the acute situation. In general, it will reflect other transitions, entrances, and exits encountered in the journey through life. In short, it will be full of unrewarded expectations and rich in unexpected complications. Reengagement with significant others will be both more and less than what was anticipated. The individual’s and the family’s sense of vulnerability will take a long time to heal. If time is taken at this point by the attending physician and his liaison consultant, much of the morbidity that has been identified in the postinfarct and postsurgical course will be better understood and more effectively addressed.

Rehabilitation Ahead of the patient and his family lies the rehabilitation course of illness. Factors relating to therapeutic efforts will depend on: severity of the individual’s physical condition; the extent to which effective grieving has occurred; the openness of communication in the family; the presence of supportive social structures, including immediate family, extended family, friends, and work; other social institutions such as rehabilitation facilities and church groups; and the patient’s personality and his capacity for hope. Many correlations have been drawn between the individual behavior patterns and proneness to coronary artery disease (15). The profile includes a man in a rush, with a chronic sense of urgency and a repressed sense of anger, who is competitive, controlled, and industrious-in short, an individual with raised arm and clenched fist, living by a stop watch. Whether or not every individual reflects this image superficially or internally, by the time of discharge, the physician-therapist will have had time to assess the behavioral patterns and personality styles of his patient and family and to identify to what extent these compromise maximum rehabilitation. Continuing assessment will identify to what extent therapy may assist modification of patterns detrimental to the health of the individual during 154

the rehabilitation period. It may be desirable to learn new approaches and skills for maximum rehabilitation, in which event psychotherapy may be an important adjunct in helping the patient to confront his feelings and review his defense patterns.

Summary The experience of a patient sustaining an acute illness has been reviewed by following him through the environments in which he is treated and identifying the sequence of stages from his and the staff’s emotional and behavioral perspective. It is suggested that effective therapeutic intervention depends upon the attention given to the patient by the primary health team with the assistance of the liaison therapist-physician and relates positively to the successful rehabilitation of the individual.

References 1. Kimball CP: Psychological responses to the experience of open-heart surgery, I. Am J Psychiatry 125348-359, 1969 2. Kimball CP: Psychological aspects of cardiovascular disease. In Freedman, Dyrud (eds). American Handbook of Psychiatry. Vol. IV. New York, Basic Books, 1975, pp. 608-617 3. Kimball Cl’: Techniques of interviewing: I. Interviewing and the meaning of the symptom. Ann Intern Med 71:147-153, 1969 Cassem NH, Hackett TP: Psychiatric consultation in a coronary care unit. Ann Intern Med 75:9-14, 1971 Engel GL: Delirium, a syndrome of cerebral insufficiency. J Chronic Dis 9:260-277, 1959 Kimball CP: Delirium. In Current Therapy. Philadelphia, W. B. Saunders Co., 1974, pp. 833-835 Kornfeld DS, Zimberg S, Malm IR: Psvchiatric complications of open l&art surgery. N Engl J Med 273:287-292. 1965 8. Kahana R, Bibring G: Personality types in medical management. In N. E. Zinberg (ed). Psychiatry and Medical Practice in a General Hospital. New York, International University Press, 1964, pp. 108-123 9. Croog SH, Levine S: Social status and subjective perceptions of 250 men after myocardial infarction. Public Health Rep 84:989-997, 1969 theory of 10. Engel CL, Schmale AH: Psychoanalytic somatic disorder: Conversion, specificity, and the disease-onset situation. J Am Psychoanal Assoc 15:344-365, 1967 11. Engel GL: Psychological Development in Health and Disease. Philadelphia, W. B. Saunders Co., 1962 12. Lindemann E: Symptomatology and management of acute grief. Am J Psychiatry 101:141-148, 1944 13. Bilodeau CB, Hackett TP: Issues raised in a group

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setting by patients recovering from myocardial infarction. Am J Psychiatry 128:73-78, 1971 14. Pinter H: The Homecoming. London, Methuen, 1965 15. Friedman M, Rosenman RH: Overt behavior pattern in coronary disease: Detection of overt behavior pattern A in patients with coronary disease by a new psychophysiological procedure. JAMA 173:1320-1325, 1960

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Direct reprint requests to: Chase Patterson Kimball, M.D. Department of Psychiatry The University of Chicago 950 East 59th Street Chicago, IL 60637

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