Steven A. Frankel

The clinical use of therapeutic disjunctions

[abstract] Disjunctions are subtle blocks to therapeutic progress. At any moment analysis can be derailed as the analyst and patient work at cross-purposes. Disjunctions may arise from internal conflict dealt with, for example, through repression coupled with projection, splitting, or dissociation, from surface incongruities such as differences between the therapist’s and patient’s styles and cultural dissimilarities, or from harder to classify factors separating therapist and patient. The concept disjunction is descriptive. Disjunction refers strictly to the restricted capacity of the analyst and patient to work together therapeutically. Conceptualizing therapeutic impasses as disjunctions, rather than, primarily manifestations of transference-countertransference, adds depth and texture to the analytic operation. It encourages partners to work cooperatively, as they resolve analytic blocks regardless of their nature.

Development of a Major Substance Use Disorder From a Patient’s Birth Through His Early Twenties

This is a pediatric case of a male patient who initially presented with multiple, nonspecific physical complaints. The patient was followed by the same pediatrician into young adulthood. These physical complaints were paired with social and academic dysfunction and a self-perception of being “unhealthy.” This is a pattern of physical expression of psychiatric illness that is referred to as somatization, and is quite common with complex patients, particularly those with very high utilization of medical services associated with minimally beneficial results. The patients ongoing and escalating pain disorder plus comorbid generalized anxiety and major depressive disorders ultimately led to a protracted and complex substance use disorder. The patient experienced major disruptions in his social and interpersonal functioning as well as profound discontinuity in his academic development as a result of his complex array of symptoms and their consequences.

A Boy with Poor Psychosocial Development and Eventual Psychotic Disorder: A Pediatrician’s Struggle to Prevail in a Hostile Treatment Environment

This is a complex pediatric case, followed from age 8 to adulthood. The patient initially presented with allergic-spectrum illness complicated by poor social and academic performance. A major disruptive issue from the start of treatment was profound disagreement between the (divorced) parents about managing their son’s healthcare. The result of this breach was disruptions of care adherence and thus, continuity. Legal involvement was ultimately necessary to manage this case. The patient’s psychiatric illness was itself complex (including elements of anxiety, depression, and psychosis) and created increased challenges in care for an already highly complex case.

Primary Care Practice: The Structures and Methods Associated with Community-Based Primary Practice

This chapter reviews the myriad factors that influence the character and quality of community- based primary care and ultimately the care experienced by the patient. To understand the work of community-based PCPs, all these factors need to be considered. An abbreviated list of these factors follows: REIMBURSEMENT: Managed care The rationale for HMO type of care payment arrangements: the traditional fee-for-service model versus shared savings Reconciliation of the disparate interests of practitioner and economy of practice Accountable care organizations (ACOs) CARE DELIVERY, COMMON TYPES: Solo practice Multi-specialty group practice Major medical center WHO DELIVERS THE CARE? Primary care physicians Physician assistants Nurse practitioners Other physician support and supplement personnel Care managers and case managers COORDINATION OF CARE: Collaborative (integrated) care Patient-centered medical home (primary care) The Medical-Psychiatric Coordinating Physician Model of Care (MPCP) Administrator-led models

Community Care, an Optimal Setting for the Treatment of Complex Cases

Much of medicine is taught in large, highly structured academic medical centers, with access to multiple specialties and subspecialties for treating highly specific, at times esoteric, clinical problems. Physicians who accomplish most of their clinical training in such institutions are accustomed to the access to resources and personnel they provide. In contrast, community-based primary care practice is often more self-contained, the physician typically taking ownership of most manageable cases. The range of readily accessible invasive and other state-of-the-art technically-based procedures is more limited than in the academic medical center. However, everything considered, community-based treatment is often the preferred location for treating chronic, complex patients, since this treatment model can provide continuity of care and the often necessary personal-social “engineering” less central to care at the typical academic medical center.

Models for Managing Complex Cases in Both Inpatient and Outpatient Settings

Models of integrated, multispecialty treatment for complex clinical cases have evolved as the awareness of the ubiquity of such cases and their cost to the medical system has grown. Traditionally, primary care physicians focused mainly on treating systemic medical illness. Generally, these treatments had a dyadic (patient-primary care physician) or triadic (patient-primary care physician-specialist physician) structure. The patient’s overall care was “owned” by the primary care physician, and the physician-patient relationship was the basis of the clinical interaction. Allied health personnel such as physician assistants or nurses were regularly involved in patient care, but the physician remained central to the treatment relationship. Newer treatment models appropriate for treating complex cases tend to be comprehensive, emphasizing coordination of medical services through multidisciplinary patient care teams. With “integrated care,” the targeted pathology is generally comorbid illness, frequently consisting of combined systemic medical-psychiatric illness, but also nonmedical conditions with a psychological and social basis. Both new and older models for care for complex cases are represented in this chapter.

Clinical Complexity: The Challenge of Complexity in Medical Practice

An encouraging phrase: “integrated care,” the combined management of a patient’s systemic medical and psychiatric illnesses. However, add to this picture psychological and social difficulties, as well as problems getting health care needs met and complexity moves to the forefront. Patients of this sort, those with multiple afflictions and complicated personal requirements, need fully coordinated care, and, at the same time guidance to help them restrain indiscriminate use of provider time. Patients with a mixture of these afflictions are “clinically complex.” With these patients as the target group, integrated care has come to the fore as a pressing topic in contemporary care delivery. Identifying these patients and then treating them whether with supportive or curative treatments is a major medical and economic task at this time.

Complex treatments: the evolving place for a medical–psychiatric coordinating physician

Medicine has lost direction. You would have to look hard to find a patient, physician, or administrator who does not agree with the frustration reflected in that opinion.Managed-care andmedical-center-based-clinic patients complain that their healthcare systems are too bureaucratized, their choices too limited, and the physicians they encounter more like “gatekeepers” than “healers.” In the private practice, fee-for-service sector, the usual dissatisfaction is about the disorganization of services and lack of collaboration among physicians. Patients lament the fact that office visits have become unconscionably brief, medical treatment too impersonal, and that costs are escalating. Negotiating this fragmented system and its out-ofcontrol expense can be maddening for both patient and physician (Kovner et al., 2000; Gawande, 2007; Gawande et al., 2009; Hussey et al., 2009; Kovner, 2010). With this book we hope to do our part to confront this dilemma. We intend to make our contribution at the clinical level, ultimately through the integrated treatment model we introduce in the following chapters. This method of patient care features a physician in a newly created role; that of the “Medical–Psychiatric Coordinating Physician” (throughout this book designated byMPCP).MPCP treatment is especially applicable for diagnostically complex andmanagement-intensive complex cases (de Jonge et al., 2006; Huyse et al., 2006; Stiefel et al., 2006; Latour et al., 2007a; Leff et al., 2009; Kathol et al., 2010a; Grant et al., 2011): those involving co-morbid systemic medical and psychiatric illnesses, and excessive utilization of resources, as well as requiring the participation of multiple interacting physician providers, healthcare workers, and consultants. Throughout this book, while we spotlight this group of patients and develop the MPCP model, we also pay special attention to the essential complexity of clinical work (“clinical complexity”) (Plsek & Greenhalgh, 2001), how it impacts the resolution of all the pathologywe encounter, and how it can be bestmanaged through the use of devices for improving clinical accuracy. We designate these techniques “truing measures,” since they point the physician in the direction of technical precision and, ultimately, toward the best approximation of clinical “truth” (Campbell & Fiske,