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Comunicare si relatie

medic-pacient
.
obiective
-Tipuri si modele de relationare medic-pacient.
-Modelul biopsihosocial (George Engel).
-Teorii de baza si exemplificari.
-client, asigurat, bolnav, pacient.
-act contractual
-responsabilitatea medicului, constiinta
profesionala.
-terapia psihologica, clasificari; coeficientul
psihoterapeutic al medicamentului, efectul
placebo, noncebo; psihofarmacologia ca
psihoterapie indirecta
Tipuri de relationare medic- pacient
1.modelul activ- pasiv ( pacient n com, n intervenie
chirurgical, stomatologic,..).
2.modelul printe-copil, profesor-elev( atitudinea
autoritar, medicul care impune reguli sau atitudinea
protectoare, care apar i protejeaz- psihanaliza Freud-
3.modelul participrii mutuale, client-furnizor de servicii,
poziie de egalitate, responsabilitatea se distribuie
ambelor pri.
4. modelul intimitii ireverenioase, de prietenie sau mai
mult- model disfuncional i lipsit de deontologie
profesional- model al unei nevoi emoionale deturnate..
Comunicare interumana
Nici o disciplina nu reuseste prin ea insasi
sa justifice fenomenele de comunicare.
Pentru a face referiri la aceeasi realitate, in
campul comunicarii se reunesc etologia si
lingvistica, cibernetica si psihanaliza,
antropologia si psihologia sociala.
Comunicare-principii generale
Cand un organism viu oarecare poate influenta
un alt organism, modificandu-i natura sau
actiunea incepand cu transmiterea unei
informatii( nu prin actiunea directa, precum cea
care exercita o forta fizica ce pune in joc o
energie)
Procesele de comunicare pot fi identificate in
domenii foarte variate(lumea fizica, animala sau
umana) si se sprijina intotdeauna pe fenomene
direct observabile.
Problemele de comunicare-
Schema Lasswell 1948
5 intrebari fundamentale:
Cine?
Ce spune?
Prin ce mijloc?
Cui?
Cu ce efect?
Emitator=>mesaj=>mediu=>receptor=>
=>Impact
1949 Shannon-teorie a transmiterii
informatiei
Emitator=>codare=>MESAJ=>decodare=>=>Re
ceptor (canal)
N.Wiener( cibernetician) adauga elemente de
reglare: de ex. Feed-backul= raspunsul la
informatie.
Cibernetica valorizeaza influenta informatiei si
proceselor de adaptare in desfasurarea unei
actiuni=>reactii ale receptorului la mesajul primit
careau efecte ce influenteaza emitatorul in
momentul primirii raspunsului la mesaj, acesta
reformulandu-si mesajul( ex rezidentiat,
perceptie/gandire).
Emitator = sursa emiterii ( MASINA ,ANIMAL, INDIVID, GRUP)
Receptor = destinatarul care primeste mesajul
Mesajul= continutul comunicarii, corespunde ansamblului de semne
perceptibile care il vor stimula pe receptor, furnizandu-I informatia

Canalul=calea pe care circula mesajele,mijloacele fizice care il stimuleaza


pe receptor( mijloace sonore, vizuale..) in procesul de comunicare.
Caracteristicile lui vor defini constrangerile si limitele in privinta transmiterii
mesajului.
Codul=procesul de codare corespunde transformarii unei informatii in
semne ce pot fi intelese.semnele a caror natura depinde de canalul utilizat
se articuleaza conform unui sistem de reguli. Procesul de decodare este
posibil daca receptorul percepe si identifica semnele si intelege reguluile
care le combina. Daca repertoriul de coduri este identic si daca regulile de
decodare sunt asemanatoare, va exista posibilitatea de receptare a
informatiei.
Zgomote=fenomenele parazite care vor denatura mesajul,facand astfel
incat intelegerea sa fie dificila.interferenta mai multor mesaje prin utilizarea
aceluiasi canal, diferite tipuri de degradare a mesajului intre momentul
emiterii-codare si cel al receptarii-decodare
Referentul=se raporteaza la toate elementele situatiei si ale contextului care
l-au determinat pe emitator sa-si formuleze mesajul.
Functiile mesajului( psihologii si
lingvistii)
Skinner 1947=>doua tipuri de mesaje
Table 1 .Measures of Therapeutic Alliance
End Point Descriptors

Scale Good(1) Poor (5)


1.Patient perceives treatment as clearly being in his/her interest
and, despite anxiety, sticks to the therapeutic task without much
interruption or denial of its unpleasantness Patient has no perception that treatment is in his/her interest and shows only fleeting

andconfused or unpredictable participation in the treatment


Patient frequently volunteers relevant, personal material and is
responsive on a meaningful level, giving feedback and
elaborating on feelings and problems
Patient refuses, even when probed, to share relevant, personal
information and is silent and unresponsive, providing minimal
feedback on verbal, postural, or gestural levels
Patient is consistently and expressly positive and optimistic
regarding the usefulness of therapy
Patient is consistently negative regarding the usefulness of
therapy, and expressed feelings are of getting nowhere in
treatment
Patient shows considerable interest in and understanding of
his/her illness and the impact it has on self and others
Patient shows no interest in or understanding of his/her illness
and the impact it has on self and others
Patient has clear and realistic perceptions of the therapist,
including how the therapist feels about him/her, and is able to
maintain this view for the most part
Patient has grossly distorted or transference-dominated
perceptions of the therapist that override realistic perceptions
almost continuously and are immune to realistic criticism or
interpretation
Patient is clearly getting involved in the therapy in a meaningful
way and is relating well to the therapist, giving rise to a
consistently positive affective atmosphere
Patient clearly is not getting involved in the therapy in any
meaningful way and is not relating well to the therapist, giving
rise to a consistently negative affective atmosphere
responsabilitatea medicului,
constiinta profesionala
Cine imi da mie dreptul de a dispune de un semen al
meu?
Decat viu, mutilat si mirosind a , mai bine mort.
Rolul de medic= rol social, investitura oficiala, este unul
din rolurile care in momente deosebite confera
sacralitate gestului si mintii umane=>obligatia morala de
a lupta pentru viata in orice conditii, pentru orice fiinta
umana, de unde si dreptul nostru de a transa in favoarea
vietii o situatie de maxim pericol respectand demnitatea
constiintei de sine a semenului aflat in pericol; obligatia
de a incerca tot ce este legal si moral posibil pentru a
forta opinia unui suferind spre directia a ceea ce din
punctul profesiunii noastre este mai bine, de a incerca sa
impunem solutia medicala optima vietii.
Norme juridice ale responsabilitatii
medicale
Orice act medical, inainte de a fi un fapt este o
stare atitudinala care precede decizia si implica:
O atitudine teoretica, apartenenta la o
paradigma a cunoasterii omului,
O atitudine practica, dependenta de evolutia
cunoasterii tehnice,
O atitudine moral-antropologica( sacralitatea
vietii, libertatea umana, demnitatea umana,
deontologia actului medical)
O atitudine juridica
terapia psihologica, clasificari;
coeficientul psihoterapeutic al medicamentului, efectul placebo,
noncebo;

psihofarmacologia ca psihoterapie indirecta

Terapie prin comunicare= psihoterapie


Utilizarea programatica a comunicarii, intr-un
mod relativ standardizat, urmand o metoda
oarecare, in scopul influentarii evolutiei spre
ameliorare a unei boli in scopul prevenirii unei
boli sau alteia, a recaderilor=psihoterapie,
terapie psihologica.
Obiective precise pe care le urmareste in mod
relativ standardizat
Psihoterapii individuale
Clasificare din perspectiva cailor de abordare a psihicului
sau a psihosomaticului:
Prin intermediul intelectului
Utilizand sugestia si autosugestia
Metode de antrenament psihofiziologic
Metode de antrenament psihologic
Metode analitice
Metode actionand prin intermediul relatiilor interumane
de grup
Metode psihofarmacologice
Consiliere, p.cognitiva, nondirectiva Rogers, hipnoza,
antrenament autogen Schultz.
Constient, inconstient
Freud-inconstientul nu mai este considerat un
element static, I se rezerva un rol de prim plan in
existenta omului.
In inconstient trebuie cautate motivatiile
profunde ale comportamentelor umane.
Sediul fortelor dinamice care dirijeaza direct sau
indirect comportamentele
Principiul placerii/ principiul realitatii
Placere=satisfacerea tendintelor si nevoilor pe
care le reprezinta
cognitia
Mediator primar al sistemelor de credinte
care sunt determinantii primari ai
experientei
Mijloace terapeutice=exam. Credintelor
existente;modificarea sau inlaturarea
credintelor generatoare ale problemei sau
simptomului; orientarea ego-ului
inconstient
Depozitar al tuturor experientelor, amintirilor si
invataturilor, sursa primara a celor mai mari
resurse, sursa primara a rezolvarii problemei/
simptomului.
Mijloacele schimbarii terapeutice: activarea
indirecta a potentialului si resurselor inconstiente
pentru rezolvarea problemei/ simptomului si
imbunatatirea functionarii.,orientarea spre
personalitatea totala
Erickson: eu nu am stiut, calul a fost cel care a
stiut. Tot ce a trebuit sa fac a fost sa-l tin pe
drum.
Principalele specializari emisferice
cerebrale Tenenbaum 1996
Emisfera.stanga:
Capacitate lingvistica dezvoltata, are
nevoie de cuvinte, structureaza frazele,
respecta sintaxa,
spirit logic, analitic, rational, dorinta de
clarificare, ia decizii, planifica, executa,
atentie focalizata, constiinta timpului,
limbaj digital, nevoia de explicatie, gandire
secventiala.
Principalele specializari emisferice
cerebrale Tenenbaum 1996
Emisfera dreapta:
Capacitate lingvistica limitata si rudimentara,
Constructia de imagini,
interes in aspectele nonverbale si paraverbale,
recunoaste forme,
simt vizual dezvoltat, simt spatial, muzical,
atentie difuza, nontemporal, limbaj analogic, se
sprijina pe intuitie, gandire globala
Politici de sanatate, planificari si
servicii de sanatate
Dupa razboi, dupa 1960, s-a incurajat internarea
si a pacientilor cu boli mai putin grave, fara
formalitati legale si s-a promovat ingrijirea in
comunitate.
O politica nationala de sanatate a fost aceea ca
unitatile de psihiatrie sa se deschida in spitale
generale, nu izolate.
O mai redusa aglomerare a sectiei,
Incurajarea vizitatorilor uitati de mult timp sa
revina,
Mental handicap and disabilities in
management, but enthusiasm for
discharge to the community has often run
ahead of provision in the community for
the still partially handicapped patients sent
home, lack of supportive social work or
very poor social support.
The open- door policy/ the revolving door
policy- that means that patients often
come back, re-admissions rose, and the
average length of stay of the mental ill
patients is around two weeks or more.
The community support, tolerance of families,
friends and neighbors can became exhausted
and exasperated and when is a lack in support,
treatment and acceptance by the staff of the
public service, then it is the patient who suffers.
The Mental Health Law, also stipulates patients
rights to have autonomy, to refuse treatment,
and other ethical principle in health care in
relation to restraint and Do Not Resuscitate
Orders.
The focus on patient autonomy has
improved the development of patient
centered models of care, shared decision
making processes and stricter
requirements for consent processes but in
the same time changed important aspects
of the patient- doctor relationship.
The project MAGELLAN Moment (Global
Ethics Program- UNESCO)- science,
culture and education, based on the
morality of the reality and the true ethics,
globally accepted.
Prof. Luc Montagnier invited us to remember: PRIMUM
NON NOCERE and to permit to think about the
questions about the development of modern medicine.
He presented an alternative called THE 4 P MEDICINE:
1. predictive- anticipatory,
2. preventive,
3. personalized,
4. participative, starting from the concept of patient not
being an object, a number in a clinical trial but a person,
a human been who needs time, who needs to be listen
and to have a fruitful dialog.
One alternative is to change the vertical approach,
sequential, to a transversal view of health and
reorganization of social services, relocation of the power
between the whole the systems actors.
The recommended change is from a disease centered
system to a person centered system, health centered
system. That means, according to Luc Monagnier, to
take of health from hospitals and develop it, rise it more
in schools, institutions, everywhere in humans life. So,
first is necessary a self-change in the mind of all of us,
and an increase in the level of awareness of the
problems and in the research to solve it.
The hope is to have a more human
medicine, more open medicine, for early
prevention of chronic diseases. That
means it will be allowed for all of us to live
much more years and in the same time in
complete health.
Mental distress is often hidden by physical
complaints at the primary care level and that
social psychiatrys focus on the impact of
broader social factors in the clinical interview
allow for earlier detection and optimal treatment
of mental disorder, thus avoiding the worsening
of symptoms and associated risks. There are
severe constraints for mental health resources in
many parts of the world. In this context, mental
health trough primary care appears to be the
only viable alternative
The main criteria and characteristics and aspects of mental
health are:
1. building of his/her own self image, an identity which
recognize individual limits and qualities related to others;
2. clear perception of reality
3. adaptability in personal relationship, in different unexpected
situations;
4. integration, balance and unitary concept about life and its
values
5. autonomy- capacity to act frey and independently, capacity
to achieve ones own purposes;
6. growth and harmonious developing of a human being,
development of self, in concordance with personal ideal model.
Autonomy attitude of solving
someones problems by himself,
without asking for others person help;
capacity of creative adjustments,
capacity to accept or reject different
kind of alternatives, capacity to make
plans, to take decisios and to
accomplish them.
Psychotic diseases determine an
important disability and even a
handicap secondary to decreasing in
autonomy, mobility leisure, social
integration, economical independency.
This fact determined a burden to the
family and subsequently for the society.
From the family point of view these
means need for support, disturbed
social relationships, economical
difficulties. From the society point of
view that means request for support,
decreasing or even losing work
productivity, disturbed social
integration .
There is disagreement among ethicists and
moral philosophers on the meaning of
autonomy. The literal meaning is self rule (
auto- nomos) and its original use was in the
context of Greek City States not individual
decision-making.
Autonomy as exercising a choice: we
accept the choices that patients make and
dont interfere with their decision, whatever
that decision is.
Autonomy as moral decision-making: some
conceptions of autonomy require a framework of
normative values within which an autonomous
person must make her decisions; autonomous
choices would be that governed by principles of duty
or obligation, a responsibility on the decision maker
to make choices within the specified moral
framework in order to be truly autonomous. A
principled version of patient autonomy is that that
include a requirement that the patient makes a
settled choice in relation to medical treatment
accountability and in consideration of others.
Autonomy, integrity and identity: protecting and
encouraging peoples capacity to live their lives out
of a distinctive sense of their own character. This
conception of autonomy emphasizes the importance
of personal integrity or identity; importance of
relationships and dependency, thus a decision made
by someone other than the patient could still respect
the patients autonomy so long as the decision was
consistent with patients own values such that the
patient would identify with the decision. Both these
views of autonomy have particular relevance for long
term care.
Autonomy as procedural
requirements; Mental Capacity Act
2005; autonomous choice includes a
requirement that the patient has a
substantial degree of understanding/ or
critical reflection/ to demonstrate a
level of cognitive process that is
greater than simply making a choice.
Autonomy in practice; represent
adequate provision of information,
capacity and freedom from coercion.
An adult patient is generally assumed
to have capacity.
Balance between the principle of
respect for autonomy against other
ethical duties such as avoiding harm or
promoting benefit.
AUTONOMY
The concept of autonomy occupies a central role
in both the legal and ethical frameworks
governing clinical practice. In the latter half of
the twentieth century this new ethical principle
has emerged, resulting in many changing in
patient centered models of care, shared decision
making processes and stricter requirements for
consent processes. One important change is
from long term inpatient, to daycare patient and
to outpatient, according to the balance between
individual and public interests.
The emphasis on patient choice and its manifestation in
systems is consistent with a libertarian view of
autonomy. A valid consent to treatment requires
adequate provision of information, capacity and freedom
from coercion.
It is often necessary to make ethical treatment decisions
by assessing the details of particular cases at a local
level, according to the available resources.
Respect for patient autonomy has been discussed
as a key ethical principle in health care. Is a concept
difficult to understand from both theoretical and practical
perspective.
The legal implications of psychiatry
1. civil responsibility.
2.criminal responsibility,
3.the mental health law and individual
liberty.
4psychiatric forms of disposal for mentally
abnormal offenders.
5. management of property.
6. consent to medical treatment.
Terapeutic Adherence
Guidelines for Fostering Adherence in
Patients From Diverse Backgrounds
Respect patients' cultural beliefs regarding
medications, but be alert for misinformation
or gaps in information tied to these beliefs.
Prepare the patient for side effects, for delay
in onset, or for long duration of therapy.
Explain that some side effects may occur
that they may be tolerable. Be aware that the
stigma attached to having a psychiatric
illness may impede adherence.
Patients may believe that medications are very
powerful and may therefore reduce the dose. Check
drug levels and have patients bring in pill bottles.
Involve the family and social system as appropriate
in the treatment plan. Not involving significant
others can derail the treatment plan by giving mixed
messages. A person who plays a central role in the
patient's decision-making process can discourage
adherence. Addressing the concerns of all parties
will increase likelihood of adherence.Trust and
adherence will greatly increase when the illness and
therapy are explained in terms that the patient can
relate to and when cultural beliefs are incorporated
in explanations of the drug's action in the body
Table 4. ADHERE: A Mnemonic for
Improving Patient Adherence With
Therapeutic Regimens
A Acknowledge the need for treatment with
the patient and ask about previous
treatments used. Together determine mutual
goals and desired outcomes.
D Discuss potential treatment strategies and
options, as well as consequences of
nontreatment with the patient (consider
issues such as treatment effectiveness,
prognosis, use of complementary/alternative
medicine, brand name vs generics, off-label
uses, prescription plans, formularies, etc.).
H Handle any questions or concerns that the patient
may have about treatment (eg, fears or worries, side
effects, costs, dosage, frequency, timing, sequence,
duration of treatment, drug or food interactions,
proper storage techniques).
E Evaluate the patient's functional health literacy
and understanding of the purpose/rationale for
treatment, and assess barriers and facilitators to
adherence (eg, environmental, economic,
occupational, and sociocultural factors, family
situation and supports).
R Recommend treatment, and review the therapeutic
regimen with the patient.
E Empower by eliciting the patient's commitment
and willingness to follow through with the
therapeutic regimen.
Developed by:
Robert C. Like, MD, MS, Center for Healthy Families
and Cultural Diversity, Department of Family
Medicine, UMDNJ-Robert Wood Johnson Medical
School, Piscataway, New Jersey
Available at: The Provider's Guide to Quality &
Culture From: Soto-Greene ML, et al.
PSYCHOLOGICAL TREATMENT
The word PSYCHOTHERAPY is used in
two ways:
1. denotes any psychological treatment,
including for example counseling and
cognitive and behavioral treatments.
2.does not include
Psychological treatment
Councelling
Crisis intervention
Interpersonal therapy
Supportive psychotherapy
Eclectic
Psychodynamic
Brief insight oriented psychotherapy
Eclectic
Psychodynamic
Cognitive analytic therapy
Long-term psychodynamic
Small-group therapy
Other forms of group therapy
Marital therapy
Family therapy
Psychotherapy for children
Behavioral therapy
Relaxation training
Exposure
Methods for obsessional neurosis
Social skills and assertiveness training
Self-control techniques
Contingency management
Other behavioral methods
Cognitive-behavior therapy
For phobic disorders
Anxiety management
For depressive disorder
For bulimia nervosa
Other methods
Other methods
Hypnosis
Autogenic training
Meditation
Abreaction
Common factors in psychotherapy
Jerome Frank (1967) pointed out that all forms of
psychotherapy share certain basic processes.
He went on to suggest that these common
factors may be more important in bringing about
change than are the factors specific in each
treatment. At first this view was controversial, but
now if is widely accepted. These shared factors
are listening and talking, release of emotion,
giving information and providing a rationale,
restoring morale, prestige suggestion, and
therapeutic relationships.
1. Listening and talking. In psychotherapy the
patient talks and the therapist listens. By
listening intently, the therapist signals his
concern for the patients problems and begins to
develop a helping relationship. He detects
common themes and revealing omissions in the
patients remarks. When the therapist speaks it
is usually to comment on these matters and to
clarify ideas that have not been put into words
before.
!
But one thing in life is more certain than
taxes and just as certain as death: the
sooner you make new friends, the sooner
youll have old ones.