Boletim BaliFilename: Balint e RMP.pdfnt Romênia 42

1BULETINUL ASOCIAIEI BALINT, VOL. 11., NR. 42, IUNIE 2009

Iunie, 2009, Volumul 11, Nr. 42

Periodic trimestrial, apare n ultima decad a lunii a treia din trimestru.

Fondat - 1999

Redactor ef - Albert VERESS M.D. Sc.D.

Lector - Almo Bela TRIF M.D., Sc.D., J.D., M.A.

Tehnoredactor - Istvn PARA

Coperta - Botond Mikls FORR

Adresa redaciei:

530.111 MIERCUREA CIUC, Str. Gbor ron 10.tel./fax 0266-371.1360744-812.900, (Dr. Veress)E-mail: [email protected], [email protected], www.balint.xhost.ro

Adresa lectorului:E-mail: [email protected]

Comitetul de redacie:

Tnde BAKA, Doina COZMAN, Dan Lucian DUMITRACU, Evelyn FARKAS, Liana FODORANU,

Ioan-Bradu IAMANDESCU, Cristian KERNETZKY (D), Mircea LZRESCU

Holger Ortwin LUX, Drago MARINESCUIoana MICLUIA, Csilla MOLDOVAN,

Aurel NIRETEAN, Iuliu OLTEANGheorghe PAINA, Ovidiu POPA-VELEA,

Almos Bela TRIF (USA)Ionel UBUCANU, va RERESS, Nicolae VLAD.

Editat de Asociaia Balint din RomniaTiprit la Tipografia Alutus, Miercurea-Ciuc

Manuscrisele sunt lecturate de un comitet de refereni, care primete manuscrisele cu parol, fr s cunoasc numele autorilor i propune eventualele modificri care

sunt apoi transmise autorului prin intermediul redaciei. Decizia lor este necontestabil.

Toate drepturile de multiplicare sau reeditare, chiar i numai a unor pri din materiale aparin Asociaiei Balint.

Plata abonamentului i a cotizaiei se face n cont CEC Miercurea Ciuc, nr. RO26CECEHR0143RON0029733,

titular Asociaia Balint, cod fiscal: 5023579 (virament) sau 25.11.01.03.19.19 (depunere n numerar). Preul unui numr la

vnzare liber este de 2 EURO/numr la cursul BNRdin ziua respectiv.

Abonamentele pentru rile occidentale cost 50 EURO/an, incluznd taxele potale i comisionul de ridicare a sumei din

banc.

INDEX: ISSN 1454-6051

BULETINUL ASOCIAIEI BALINT DIN ROMNIA

CUPRINS

RELAIA TERAPEUTIC N REACTIADE DOLIU INDUS DEPIERDERILE MULTIPLE ........................................ 3Oana Cornelia Dobrescu, Voichia Dumitru,Dana Cristina Hera

A SPECIAL FIELD FOR THEBALINTIAN GROUP - HELPLINE SERVICE ........ 7Istvan Varadi

RELAIA MEDIC-PACIENT N CADRUL UNEICOMUNITI TERAPEUTICE ............................. 10Lux Holger Ortwin

THE IMPORTANCE OF STRONG WORKING ALLIANCES IN BALINTGROUP DEVELOPMENT ....................................... 13Richard B. Addison, U.S.A

PIERDEREA I DOLIUL LA PACIENIIONCOLOGICI I FAMILIILE ACESTORA .......... 17Ioana OMER, Onica Ilisei

RECLAIMING THE UNCONSCIOUSIN BALINT GROUP WORK .................................... 21Alan H Johnson, USA

TIRI DIN VIAA ASOCIAIEI ............................ 28


Prezentarea ASOCIAIEI BALINT DIN ROMNIA

Data nfiinrii: 25 iulie 1993

Michael BALINT: Psihanalist englez de origine maghiar

Grupul BALINT: Grup specific alctuit din cei care se ocup de bolnavi i care se reunesc sub conducerea a unui sau a doi lideri, avnd ca obiect de studiu relaia medic-bolnav prin analiza transferului i contra-transferului ntre subieci.

Activitatea Asociaiei:grupuri Balint,editarea Buletinului,formarea i supervizarea liderilor,colaborare la scar internaional.

Specificul Asociaiei: apolitic, nereligioas, inter-universitar, multi-disciplinar, de formaie polivalent.

Obiective: Formarea psihologic continu a partici-panilor. ncercarea de a mbunti prin cuvnt calitatea relaiei terapeutice medic-pacient i a comunicrii dintre membrii diferitelor categorii profesionale. Rol de punte ntre etnii, confesiuni, categorii sociale, regiuni, ri.

BIROUL ASOCIAIEI:Preedinte: Tnde BAKA [email protected]: Istvn VRADI istvanvaradi1inbox.comSecretar: Csilla HEGYI [email protected]: Albert VERESS [email protected]: Rita-Lenke FERENCZ, Holger Ortwin LUX, Attila MUNZLINGER, Ovidiu Popa-Velea, va VERESS.

Cotizaia se achit pn la 31 martie a.c. Cvantumul ei se hotrte anual de ctre Biroul Asociaiei. n cazul cnd ambii soi dintr-o familie sunt membrii Asociaiei, unul din ei poate cere scutirea de la plata abonamentului la Buletinul Asociaiei, al crui cost se stabilete anual.

Cei care nu achit cotizaia pn la data de 31 martie a anului n curs nu vor mai primi Buletinul din luna iunie, iar cei care nu vor plti cotizaia nici pn la data de 31 martie a anului urmtor vor fi penalizai cu o majorare de 50%!!! Cei cu o restan de doi ani vor fi exclui disciplinar din Asociaie.

Studenii i pensionarii sunt scutii de plata cotizaiei, fiind necesar doar abonarea la Buletinul Asociaiei.

Cotizaia pentru anul 2009 este de 20 EURO (la cursul oficial BNR din ziua n care se face plata), n care se include i abonamentul la Buletin.

Taxa de nscriere n Asociaie este de 20 EURO (nu se face reducere nici unei categorii socio-profesionale). Abonamentul cost 6 EURO.

Se primesc articole cu tematic legat de activitatea grupurilor Balint din Romnia i din strintate, de orice fel de terapie de grup, de psihoterapie, de psihologie aplicat i de alte abordri de ordin psihologic al relaiei medic - pacient (medicin social, responsabilitate medical, bioetic, psihosomatic, tanatologie).

Materialele scrise la solicitarea redaciei vor fi remunerate.

Buletinul este creditat de ctre CMR ca prestator de EMC, deci orice articol publicat se crediteaz cu 25 de credite EMC. Abonamentul la Buletin se crediteaz cu 5 credite.

Redactorul ef i / sau lectorul au dreptul de a face cuvenitele corecturi de form, iar n cazul neconcordanelor de fond vor retrimite articolele autorilor cu sugestiile pentru corectare.

Deoarece revista se difuzeaz i n alte ri, articolele care nu se limiteaz doar la descrierea evenimentelor balintiene, trebuie s aib un rezumat n limba romn i englez, de maximum 10 rnduri dactilografiate. Lectorul i asum responsabilitatea de a face corectura rezumatului

Pentru rigoarea tiinific apreciem menionarea bibliografiei ct mai complet i mai corect, conform normelor Vancouver, att pentru articolele din periodice ct i pentru monografii (citarea n text se noteaz cu cifre n parantez, iar n bibliografie se nir autorii n ordinea

citrii nu cea alfabetic i doar acei autori care au fost citai n lucrare).

Recenziile crilor trebuie s cuprind datele de identificare a crii n cauz - autorii, titlul, toate subtitlurile, anul apariiei, editura, oraul, numrul de pagini i ISBN-ul. Se trimite n fiier separat imaginea scanat a copertei.

Se primesc doar materiale trimise pe diskete floppy de 3,5, CD room, memory-stick sau prin e-mail ca fiier ataat. Se vor folosi numai caractere romneti din fontul Times New Roman, culese la mrimea 12, n WORD 6.0 sau 7.0 din WINDOWS.

Imaginile - fotografii, desene, caricaturi, grafice - vor fi trimise ca fiiere separate, cu specificarea locului unde trebuie inserate n text pentru justa lor lectur. Pentru grafice este important s se specifice programul n care au fost realizate.

Articolele trimise vor fi nsoite de numele autorului, cu precizarea gradului tiinific, a funciei i a adresei de contact, pentru a li se putea solicita extrase. Autorii vor scana o fotografie tip paaport sau eseu pe care o vor trimite ca fiier ataat sau pe o disket la adresa redaciei.

CTRE AUTORI


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Asociaia Balint are un site. Adresa: www.balint.xhost.ro

Autorii sunt rugai s se conformeze regulilor de redactare a articolelor.

RELAIA TERAPEUTIC N REACTIA DE DOLIU INDUSDE PIERDERILE MULTIPLE

Dr. Oana Cornelia Dobrescu*, psiholog Voichia Dumitru**,Dr. Dana Cristina Hera*

* UMF Cluj-Napoca, ** Clinica Psihiatrie III Cluj-Napoca

ANUNURI IMPORTANTE

Rezumat: Pierderea unei fiine dragi, a sntii, a unei slujbe,

a unui vis sau sperane, sunt evenimente nefericite prin care trecem cu toii mai devreme sau mai trziu n aceast via. Reacia de doliu se refer la acele emoii negative, stri fizice i manifestri de ordin social, care nsoesc aceste pierderi. Pierderile suprapuse sau cumulate cresc riscul apariiei unor reacii de doliu complicate, sau patologice, care necesit o intervenie terapeutic susinut. n literatura de specialitate se vorbete despre o stadializare a reaciei de doliu, considerat ns arbitrar, iar medicalizarea excesiv a unor reacii normale la pierdere sunt aspru criticate. Pentru a evita apariia doliului complicat, consilierea faciliteaz exprimarea emoiilor, construirea unor noi tipuri de relaii fr cei pierdui, deci reconstruirea lumii interioare a fiecrui individ aflat n doliu.

Cuvinte cheie: pierderi, reactie de doliu, stadializare doliu, doliu patologic

Abstract: The loss of a loved one, of health, a job, of a dream or

a hope are unfortunate events we all pass through sooner or later in this life. Grief refers to those negative emotions, physical states and social behaviors that accompany this loss. Cumulative losses increase the risk of complicated, pathological grief reactions, necessitating a sustained therapeutic intervention. In the literature are presented some grief stages, but these are considered arbitrary, and the excessive medicalization of some normal reactions to loss is fiercely criticized. In order to avoid complicated grief, the counseling offered to bereaved persons facilitates the completion of the relationship with the lost person or object, by expressing the emotions connected, the construction of new types of relationships, without the lost ones, by reconstructing so the inner world of every bereaved person.

Key words: loss, grief, grief stages, pathologic grief

Reacia de doliu reprezint totalitatea emoiilor, de obicei negative, dureroase, aprute n urma unei pierderi majore [1, 2]. Dei n mod curent, reacia de doliu ne duce cu gndul la suferina cauzat de moartea sau dispariia unei persoane dragi, sau a unui animal de companie,

specialitii vorbesc de reacie de doliu ca rspuns specific oricrei pierderi, fie c este vorba de pierderea unei fiine dragi, sau de pierderea unei relaii, cum este cazul divorului, a strii de sntate, a unui membru sau organ, sau a unei funcii, pierderea controlului, cum se ntmpl n cazul dezastrelor naturale sau produse de oameni, a accidentelor, pierderi sociale, pierderea slujbei, a casei, etc [3]. Autori precum Kissane (2000) [4], definesc pierderea ca fiind deprivarea de ceva investit cu semnificaie emoional de ctre individ. n limba romn termenul de doliu include att pierderea prin moarte a unei persoane iubite, avnd ca echivalent n limba englez termenul de bereavement, ct i procesul de adaptare la o astfel de pierdere, incluznd ritualurile sociale i culturale ce acompaniaz decesul unei persoane, i care n limba englez sunt circumscrise termenului de mourning [4]. Reacia de doliu s-ar suprapune peste termenul englez grief, care include sentimentele i emoiile care nsoesc procesul de adaptare la o pierdere, deci acel mourning. Reacia de doliu include pe lng reaciile emoionale tip tristee, disperare, anxietate, mnie, vinovie, i reacii somatice, precum tulburri de somn, de apetit alimentar, hipersensibilitate la zgomote, dificulti de concentrare a ateniei, agitaie i nelinite, precum i reacii sociale, dintre care cea mai frecvent ntlnit este izolarea [5].

Pornind de la studiile efectuate de Lindemann cu ocazia catastrofei produse n urma incediului unei discoteci din Boston, Cocoagrovenut, n 1944, soldat cu nenumrate victime, au fost descrise o serie de caracteristici ale supravieuitorilor. Printre acestea se numr o stare de amorire emoional, preocupri cu amintirea celui decedat, stri confuze de mnie, vinovie, tulburri ale patternului comportamental obinuit, chiar identificarea cu simptomatologia persoanei decedate.

Interesul crescnd pentru intervenia n cazul doliului complicat a fcut ca stadializarea reaciilor emoionale prin care poate trece o persoan avnd o boal n stadiul terminal, descris de Elisabeth Kubler-Ross n cartea sa On death and dying, s fie transferat i n cazul reaciilor de doliu. Acest lucru a strnit nenumrate confuzii i controverse. Autori precum Friedman i James [6] consider n primul rnd c nu putem vorbi de reacii universale de doliu, c acestea depind de nenumrai factori i c sunt reacii foarte personale, individuale.


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Plecnd de la analiza aprofundat a crii lui Kubler-Ross, dar i de la experiena personal i profesional cu reacia de doliu, aceti autori consider c negarea, primul stadiu propus de autoarea crii On death and dying n-ar fi de fapt dect o figur de stil, i nu o credin ntemeiat printre persoanele ndoliate,

Totodat, aceeai autori atenioneaz c mnia nu este neaprat o reacie universal de doliu, ea putnd apare n legtur mai ales cu anumite tipuri de pierderi, c negocierea se ntlnete mult mai rar n situaiile de doliu i mai frecvent printre pacienii n fazele terminale ale bolilor, i c ideea de vinovie poate fi adesea indus iatrogenic, cauznd mai mult ru dect ajutnd persoana ndoliat.

Mai mult, starea de amorire emoional (numbness) ar fi doar o reacie ce dureaz de obicei prea puin pentru a putea fi catalogat ca i stadiu. De fapt, pentru aceti autori, noiunea de stadiu presupune un cadru temporal, care poate induce ideea, fals i adeseori periculoas, c dac atepi suficient timp, acea stare va trece de la sine. Aceast atenionare este valabil n special pentru stadiul depresiei, cnd reaciile comune de doliu, de tipul tulburri ale ateniei, somnului, apetitului alimentar, lipsa energiei i labilitatea emoional, se pot confunda cu simptomatologia unei depresii clinice. Aceasta poate conduce fie la o fals etichetare ca depresivi a unor indivizi aflai ntr-o stare normal de tristee, cauzat de o pierdere important, fie, poate mai grav chiar, la etichetarea ca stadiu normal al reaciei de doliu a unei depresii clinice, i la ateptarea ca acest stadiu s fie depit, pierzndu-se astfel un timp preios pentru persoana n cauz. De altfel, att Friedman i James1 [7] ct i Carol Crandall2 [8] consider c nu timpul vindec prin el nsui, ci ceea ce faci n tot acest timp, sensul pe care l dai pierderii suferite, i modul cum aceast pierdere este integrat vieii individului.

Dat fiind universalitatea reaciei de doliu la pierderile importante, dar i modul individual, personal n care fiecare din noi rspundem la diferite pierderi, cercettorii n domeniu s-au artat foarte preocupai de diferiii factori care ar putea explica de ce unele persoane trec mai uor prin reaciile de doliu, n timp ce altele vor dezvolta diferite patologii somatice sau psihologice, innd de aa numita reacie de doliu complicat sau patologic. Dei nsi noiunea de doliu complicat sau patologic este destul de criticat n literatura de specialitate, totui au fost descrise nc din 1965 de Parkes [9] diferite forme de doliu patologic: cronic, ntrziat i inhibat care ulterior au fost reformulate de Volkan, 1970, Parkes, Weiss, 1983 i Stroebe and Stroebe, 1987 [9], ca i sindrom de doliu neateptat, ambivalent i cronic. Aceste tipuri de reacii patologice, asociate mai frecvent cu tulburri de anxietate, depresie, suicid, reacii psiho somatice sau sindromul de stress posttraumatic [4] au fost asociate unor factori de risc dintre care amintim: relaiile pre existente cu persoana decedat,

n care ambivalena i relaiile nerezolvate joac un rol esenial, tipul morii, rspunsul familiei i reelei de suport social, alte situaii de criz sau stress concurente, vrsta la care apare pierderea, sexul, clasa socio-economic, gradul de religiozitate, personalitatea individului [9, 10], i nu n ultimul existena unei patologii anterioare pierderii, a unei depresii [6].

i dac pentru situaiile de doliu patologic specialitii sunt unanim de acord cu necesitatea unei intervenii terapeutice ferme, att farmacologice ct i psihoterapeutice, n ceea ce privete oportunitatea i beneficiul unei consilieri n situaiile de doliu necomplicat, prerile sunt net mprite, unii considernd chiar c astfel de intervenii, departe de a aduce un beneficiu clientului, mai ru l mping n braele unei iatrogenii, prin medicalizarea forat a unor stri normale de doliu. Pentru a preveni apariia unui blocaj n derularea normal a unei reacii de doliu, i apariia unor complicaii patologice, Friedman i James, membri fondatori ai The Grief Recovery Institute consider ca esenial terminarea, completarea relaiei cu persoana disprut sau cu partenerul divorat, prin comunicarea prin diferite tehnici, a tuturor emoiilor, gndurilor legate de acea relaie, chiar i atunci cnd cellalt nu mai poate rspunde sau nu se poate schimba [11]. Aceasta n ideea n care o astfel de relaie neterminat poate conduce la credina nefondat a necesitii unei suferine perpetue i a imposibilitii schimbrii i a regsirii fericirii pierdute [12]. O alt metod predicat de cei doi autori este mprtirea amintirilor, a sentimentelor legate de persoana i de relaia pierdut [13], precum i admiterea, recunoaterea suferinei, a emoiilor negative de mnie, team, durere, tristee legate de aceste pierderi, i nu negarea i represia lor, ceea ce s-ar solda cu efecte negative pe termen lung [14].

Vom prezenta n continuare cazul doamnei V. internat n Clinica de Psihiatrie III cu o complicaie de tip depresiv a unor reacii de doliu suprapuse, rezultate n urma unui avort indus i a pierderii unui organ, respectiv n urma unei histerectomii cauzat de infecia produs de un sterilet introdus post abortum. Doamna V., n vrst de 43 ani, mama unui biat de 21 ani, recstorit de 19 ani, n urma decesului primului so, se prezint la internare cu o simptomatologie polimorf, de tip depresiv, cu idei de incurabilitate, de inutilitate, ideaie suicidar pasager fr plan organizat, tristee, anhedonie, apatie, scderea randamentului activitilor cotidiene, izolare social i n cadrul familiei, nsoit de numeroase simptome somatice tip cefalee, senzaii de arsuri n corp i mai ales abdominale, transpiraii att diurne ct i nocturne, valuri de cldur, tulburri de somn i inapeten. Simptomatologia actual a debutat insidios de cca. 2 ani, n urma unei histerectomii totale cauzate de complicaiile induse de un sterilet. Pacienta a primit dup operaie tratament substitutiv hormonal,

1 Time does not heal. Time goes by. It is the actions that you take within time that can help you grieve and complete relationships that have ended or changed. Timpul nu vindec. Timpul doar trece. Aciunile pe care le faci n acel timp te pot ajuta s te despari i s termini relaiile care s-au ncheiat sau care s-au schimbat (nt.)2 You dont heal from the loss of a loved one because time pases; you heal because of what you do with the time. Nu te vindeci de pierderea unei persoane iubite pentru c timpul trece; te vindeci datorit a ceea ce faci cu acel timp.(nt.)


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pe care ns nu l-a urmat dect cteva luni, precum i tratament antidepresiv, la care ns s-a dovedit total non compliant, fiindu-i team s nu devin dependent de aceast medicaie. Aceste idei au fost introduse i meninute de anturajul apropiat al pacientei, n special de mama sa, foarte intrusiv, critic la adresa pacientei i autoritar. Din antecedentele pacientei reinem o serie de evenimente traumatice: moartea timpurie a primului so, foarte iubit, dup care a rmas cu un copil mic de crescut; acesta este momentul cnd doamna V. se apropie foarte mult de prinii si care o ajut din punct de vedere profesional, deschiznd mpreun cu mama o afacere comercial a crei ef este mama pacientei. Urmeaz apoi o cstorie cu un brbat obinuit s comande i s hotrasc totul n cas, ceea ce face din doamna V. o persoan obedient, care din cnd n cnd i permite s mai hotrasc i singur, ns numai n ceea ce o privete pe ea personal, i niciodat n ceea ce privete relaia lor sau n problemele legate de gospodrie. n urm cu cca. 3 ani pacienta rmne nsrcinat cu cel de al doilea so, ns hotrte, de una singur, c soul nu este pregtit s accepte rolul de printe, fiind centrat prea mult pe reuita n afaceri, i face o ntrerupere voluntar de sarcin despre care nu vorbete nimnui. Ulterior, decide s utilizeze ca i metod contraceptiv un sterilet, care ns va fi cauza unei infecii uterine, care va conduce, dup multe peregrinri pe la diferii medici ginecologi din diferite orae, la o histerectomie total. n timpul internrii pacienta se plnge la nceput zilnic de cefalee, senzaii neplcute de arsuri corporale, valuri de cldur i transpiraii, precum i de o senzaie de gol abdominal, acolo unde i imagina ea ca a fost uterul ce i-a fost scos. Gndurile sale erau centrate n totalitate pe pierderea uterului i odat cu el a feminitii sale, pe pierderea sntii i a volumului su anterior de munc, n momentul internrii pacienta nemairecunoscndu-se n ceea ce a fost odat. Impresia pe

care doamna V. o ddea personalului medical era a unei femei ce se aga cu disperare de durerea i nefericirea sa, care parc i procurau singura plcere posibil nc pentru ea. Compliana la tratamentul antidepresiv a fost marcat de o evoluie ondulant, n sensul n care atunci cnd se simea foarte demoralizat i neputincioas l accepta, pentru ca n momentul n care se simea ceva mai bine, s renune la el, de teama unei dependene. Astfel, n momentul internrii sale, pacienta ncercase deja mai multe tipuri de antidepresive de care se plngea c nu au avut nici un efect benefic. n timpul spitalizrii, pacienta primete un nou tratament antidepresiv, Coaxil, la care s-au adaugat o serie de edine de narcoanaliz, ce au permis accesarea unui nucleu de nemulumiri i frustrri personale, att pe plan sexual, marital, ct i pe planul relaiilor interpersonale dominate de mama i de soul su, emoii care au constituit ulterior baza discuiilor terapeutice. De asemenea, a fost abordat tema avortului i a tririlor generate de acesta, precum i de pierderea uterului, legat n reprezentrile pacientei de pierderea feminitii sale i a interesului soului pentru ea, dar i de pierderea interesului su pentru actul sexual, ca i pentru apariia sa fizic. Totodat, s-au folosit cteva edine de expresie grafic, tip artterapie, care a facilitat mobilizarea, contientizarea i numirea diferitelor emoii negative. Expresia grafic urmrete s dea posibilitatea pacientului s se exprime i s se reprezinte prin intermediul formelor, simbolurilor i culorilor, s utilizeze suporturile de exprimare non verbal i verbal, cu o puternic not de personalizare.

La acestea, s-a adugat o edin de consiliere de cuplu, n care celor doi soi li s-a facilitat deschiderea ctre comunicarea referitor la dificultile din cuplu, la ateptrile fiecruia de la partenerul de cuplu, precum i despre pierderea funciei reproductive. Prin toate aceste tehnici psihoterapeutice au fost vizate schematele cognitive fixate,

Cerc magic


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precum faptul c pierderea uterului nseamn c nu mai sunt femeie, am un gol n abdomen, etc, ajungndu-se n final la atenuarea acestor gnduri i modificarea imaginii de sine. Evoluia cazului a fost lent dar favorabil, n sensul n care simptomatologia fizic i psihologic cu care s-a internat a diminuat n mod semnificativ, iar pacienta a reuit s depeasc blocajul centrat pe pierderi i s-i priveasc viitorul ca pe ceva plcut i realizabil.

Ceea ce s-a ntmplat cu doamna V. n timpul spitalizrii poart n literatura de specialitate numele de grief work i presupune reorientarea gndirii ctre pierderea suferit i ctre emoiile dureroase implicate de aceast pierdere, exprimarea acestor emoii n cuvinte, ceea ce permite n timp reorganizarea lumii interne a individului, adaptarea la o nou etap de dezvoltare n absena fiinei, situaiei sau organului pierdut [10]. n cazul doamnei V. putem vorbi de o serie de pierderi semnificative de-a lungul vieii sale, urmate de reacii de doliu mai mult sau mai puin rezolvate, dar care s-au acumulat n timp, conducnd la credina fals c ea nu va mai fi niciodat ceea ce a fost cndva, c nu se va mai face bine niciodat i c nu va mai fi niciodat fericit, de unde contemplarea destul de frecvent a morii.

Histerectomia, ca i procedur chirurgical invalidant, se nsoete adesea de o serie de reacii emoionale negative de tipul anxietii i depresiei, de reacia de doliu secundar pierderii funciei reproductive, precum i de teama de raporturi sexuale nesatisfctoare, legate uneori de modificrile fiziologice induse de extirparea ovarelor [15]. Mai mult dect att, o ntrerupere voluntar de sarcin se nsoete adesea de o reacie de doliu mai profund i mai ntrziat dect n cazul unei pierderi perinatale, ntruct aceast pierdere este cel mai adesea nemrturisit, ascuns i ncrcat de un sentiment de ruine i vinovie real i obiectiv [16]. Emoiile negative pot s se perpetueze i s se complice, ca i n cazul doamnei V., iar cererea de ajutor pentru o depresie sau o alt complicaie a unui doliu nerezolvat poate apare dup ani de zile, cnd legtura cu evenimentul traumatizant cauzal este mult mai greu de stabilit.

n astfel de cazuri, chiar dac farmacoterapia induce o anumit ameliorare a strii psihice a subiectului, psihoterapia este cea care va permite accesul la aceste evenimente traumatice profund reprimate, parcurgerea pailor dureroi ai panicii, repulsiei i urii pentru a ajunge la acceptarea realitii i a responsabilitii pentru cele ntmplate [16]. Din nefericire, att societatea, n general, ct i seciile de ginecologie, n particular, sunt prea puin, sau deloc pregtite pentru a facilita exprimarea tuturor emoiilor negative asociate diferitelor pierderi (de organe nalt investite emoional, precum uterul i ovarele, dar i a embrionilor, fetuilor, sau nou-nscuilor mori la natere).

Sensibilizarea echipei terapeutice la astfel de subiecte, i apoi a pacientelor, prin educaie sanitar, ar putea constitui nu doar un deziderat medical ci i o metod de prevenie a diferitelor complicaii induse de pierderile nerezolvate.

Bibliografie:

1. Gale Encyclopedia Of Psychology 2Nd Ed, pp. 397-399, 2001 2. Stedmans Medical Dictionary, 28th Edition. 2006. Lippincott

Williams & Wilkins 3. http://www.helpguide.org/mental/grief_loss.htm4. D. Kissane. Loss, Grief and Bereavement. http://www.ipos-

society.org/professionals/meetings-ed/core-curriculum/bereavement/en/player.html

5. http://en.wikipedia.org/wiki/Grief 6. Russell Friedman & John W. James. The myth of the stages

of dying, death and grief. http://www.grief.net/Articles/Myth%20of%20Stages.pdf

7. Russell Friedman & John W. James, Right or Happy...Pick One http://www.grief.net/Articles/Right_or_Happy_Pick_One.htm

8. Grief Counseling And Therapy http://www.deathreference.com/Gi-Ho/Grief-Counseling-and-Therapy.html

9. M. Bradbury. Representations of death. A social psychological perspective, Routledge, London, 1999

10. M. Allen, S. Marks. Understanding grief. ht tp://www.obgyn.net/pregnacy-bir th/pregnacy-bir th/

articles/grief_allen_1115 11. Russell Friedman & John W. James Less Than Loved Ones-

Hopes and Dreams, http://www.grief.net/Articles/Less_Than_Loved_Ones.htm

12. Russell Friedman & John W. James. Am I Equipped for Happiness? http://www.grief.net/Articles/Am_I_Equipped_for_Happiness.htm

13. Russell Friedman & John W. James. Am I Paranoid, or are People Avoiding Me ?, http://www.grief.net/Articles/Am_I_Paranoid.htm

14. Russell Friedman & John W. James. Im Fine... and Other Lies!!! http://www.grief.net/Articles/Im_Fine_and_Other_Lies.htm

15. Emotional reactions to hysterectomy. http://www.svcmc.org/18680.cfm

16. E. J. Angelo. Psychiatric sequelae of abortion: The many faces of Post-Abortion grief. Linacre Quaterly, vol 59, no2, 1992. http://www.hopeafterabortion.com/aftermath/index.cfm?page=angelo

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Abstract:In our-days globalized and postmodern world East-

European human professionals can face newer, unexplored social demands. Balintians can give a great contribution in several ways to those initiatives that reach for answers and solutions for these demands. A special field of balintian work is the Balint group for Helpline Service team. In this paper the Author underlines some of the typical aspects of this work, concerning particularities of the HL service, of this kind of Balint group and the difficulties of the group leader.

Key words: globalization, helpline, concerning parti-cularities

We must continue to offer the experience to everyone so that is available for those who need it. We must continue our research so that we can demonstrate some of the beneficial effects. We must go on training group leaders. We will never change all the light bulbs but we must keep on enough lights to enable people to know we are still here: enough light for everyone who needs to read our message.

- John Salinsky -

I. The ChallengeIt sounds like a common place but its true: we live

today in a postmodern and globalized world. Without trying to do a deeper analysis of these terms we can state that they have a specific meaning in East-Europe. It is well known and described in meteorology that the natural phenomena are the most unstable, noisy, confusing and dramatic at the frontline of cyclones and anticyclones. We can consider East-Europe as a frontline of globalization and postmodern way of thinking. Examination, description and analysis of social changes are subject of sociology; the matters of politics are to develop appropriate answers, attitudes and strategies. The question is: what the doctor or human professional can or has to do at the frontline of changes. The need for crossing over the biomedical paradigm and taking the psychosocial aspects into consideration has never been as emphatic as it is today. In my opinion the doctor has only two options: to ignore the reality if he/she prefers the self-isolation in the professional (in a way, very protective) ivory tower, or he/she to recognize the new challenge and to assume a new, broader social mission.

For balintian doctors it is obvious that discussing exclusively on the doctor-patient relationship we can only touch the top of the iceberg. Without the doctors high social sensitivity the whole underwater world can remain mysterious and mostly unexplored, hidden for him/her. That could be the reason why several Romanian Balint

groups instinctively involve non-medical professionals into their work: psychologists, social workers, teachers, family therapists and even lawyers, engineers and economists.

I would like to point out from the group leaders point of view some particular aspects of balintian work in a very special field: the helpline service.

Even if it has a more than fifty years history, the helpline does appear as an essentially globalized and postmodern answer to the globalized and postmodern demands of society.

Our HL service started in 2005 in Harghita County, a quite isolated mountain area with the highest prevalence of suicidal events, depression, alcohol abuse and violence all around Romania.

The team of our Service consists of specially trained helper professionals and volunteers. Primordial goals of the Service are suicide- prevention, crisis intervention, supportive assistance and data base function. Our Statement is based on IFOTES (International Federation of Telephonic Emergency Service) principles and ethic codes regarding the goals, privacy, neutrality, professional standards, and voluntaries and so on.

Below I would like to underline some particular difficulties a group leader might face in a Balint group for HL team.

II. Relationship particularities, the helpers special problems

1. Problems of controlling, initializing The caller is the one who establishes the theme and the

orientation of the conversation the caller is the one deciding when to place the call, the

helper cannot interfere the caller decides when the conversation ends the conversation depends on the caller. He is the one

deciding the speed and rhythm of the conversation (there can be more minutes of silence, rhythm changes because of the emotional changes/swing. The helper can only follow this imposed rhythm and speed.

It depends on the caller whether he speaks at all It depends on the caller whether he introduces him-self

or not The tonality, vocabulary, manner depends on the caller

2. Problems of intimacy and privacy The helper does not know the caller (and probably will

never know) The caller does not know the helper (and he may not!) If the caller recognizes the helper or the other way,

the helper must manage the situation to sustain the anonymous relationship.

A SPECIAL FIELD FOR THEBALINTIAN GROUP- HELPLINE SERVICE

Dr. Istvan Varadi, MD., General practitioner, Romania


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3. Lack of stable frames The relationship is occasional; the helper must help only

during this one meeting. It cannot be planed: the helper does not know in advance

what the problem might be, how much the caller tells about that particular problem, how much time do they have to discuss about the problem, when the caller will end the conversation.

There is no contract between them; the caller has no moral responsibility.

Because of the factors discussed, the frame is very loose; the helper must handle the conversation without any stable base, just improvising.

4. Lack of visual/personal contact the helper cannot evaluate the body language of the

caller the helper cannot give feedback through body

language there are only vocal meta-communication possibilities,

these being the most important: vocal volume tonality communication manners rhythm, intermission, fastness does the caller speak immediately or keeps

silence for a while how many silent calls were before he spoke background noises, voices

5. Lack of feedback, case follow-up the helper usually does not know the result of the

conversation (especially in a case of suicidal crisis) if still there is an appointment for a date-fixed call: What happens if the caller does not call?

What happens if the caller calls too many times, becoming an addicted, chronicle caller?

III. The nature of the group (particular problems of the group) the members are not necessarily trained helpers (mostly

without any previous experience in group work or supervision )

there are always more cases than the group could handle at a time

The time limits are flexible: we know when we start, but we dont know when we are going to close the group

The narrative of the case holder has a great importance every detail is important because of the minimal information.

the questions point the dynamic of the caller-helper discussion: What was the first sentence? Why did he call now? How did he get there to call? What was like the tonality, speaking manner? Rhythm? Fastness? Intermissions? What was the declared expectance of the caller? What was the hidden expectance of the caller? What were the expressed emotions? What were the expressed emotions towards the helper? What were the emotions of the helper? The phantom portrait of the caller the fantasy and non proven hypothesis

have a great role in the group discussion great emotional intensity the emotional transfer is fast and very intensive the group members experience a great emotional saturation even after the group work.

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IV. The particular problems of the group leader (resulted from the situation described before)

1. In the group structure big group number, usually over 15-16 members Enlarged small group? Fishbowl with external group working as a reflecting team? The diversity of professionals and volunteers from

different working areas, usually without any or little balintian experience.

More helper generations in the group, the problem of integration of the new members ( how to motivate new generations or members for an active, participative presence).

2. In the time structure The group always needs more than 60-90 minutes to finish a case.

There can be new members in the group who need to come to know the balintian work procedure. There is no need to present the psychodynamic depths; it is enough to present the group working method. It can be presented by the group leader or by an older member.

The time frame of the different sections (case introduction questioning discussion) may be changing, according to the particular situation/case. Every part can be longer than the usual balintian group work. The group leader can interfere but cannot be intrusive!

There is always needed time for reflection, for emotions to settle down not only for the case holder, but for the whole group.3. In the group dynamic structureSelecting the case: usually there are more cases than

the group could handle in one group; In our experience the group can work properly only with one case. It is difficult and delicate job for the group leader to lead the group to choose a case. The decision is made by the group with the constant supervision of the leader.

The narrative of the case holder: little information, many emotions, it is the most important not to settle time limits, the

presentation will be anyway self-limited, the case holder can be encouraged to talk about his/her

feelings, fantasies and anxieties The phantom-portrait of the unknown caller and the map

of relationships which develops from this information. Questioning: (as a general rule): no time pressure on

the group! having a great emotional substance, it needs time to ask and answer a question. The silent moments are very important.

Discussions: The leader can help the group not to orientate towards

the solution of the problem, but let the emotions, fantasies, doubts, anxiety to flow.

The group members usually recall their own caller problems, they incline to emphasize with the case holder.

At the end of the discussion it usually helps if the group members can formulate a good-bye sentence in the name of the caller.

Ending the group It is very important to ask the group feedback after the

case holders intervention. It is particularly important to ask about the emotions of

those group members who renounced to their own case. They can ask for personal supervision or just wait for the next balintian group to come.4. Regarding personality of the group leader:

an accurate experience as a Balintian group leader good experience in Help Line work to be avoided if possible a permanent Help Line worker,

it is advisable to be an external group leader. continuous self- development and supervision

Final conclusionsAbove I summarized our three year experience in Help

Line work. It would be very useful and constructive if these thoughts would be completed, enriched, overdeveloped by the balintians working in similar fields.

Our work confirms the use and efficiency and efficacy of the balintian method not only for medical structured groups, but also for all those individuals, groups, communities who are working voluntarily or not in the social care system and who have to deal with the difficult, complex, heavy and twisted present world.

Dare de seam, septembrie 2008

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Trebuie s fim contieni c dorinacea mai mare a fiecrui client,

respectiv pacient, este aceea de a fi neles.Michael Balint (1)

Rezumat:Comunitatea terapeutic, dei este un model consacrat

pe plan mondial i chiar veriga principal n cadrul lanului terapeutic al unor tulburri precum dependenele de droguri legale i ilegale, n ara noastr nc reprezint un pionierat. n acest cmp terapeutic special i relaia medic-pacient este una particular, procesul terapeutic fiind influenat mai ales de situaia i dinamica grupului. Abordarea este una holistic, incluznd pe lng medicina clasic psihoterapia de grup i cea individual, consilierea familiei, ergoterapia i dezvoltarea unor aptitudini sociale.

Cuvinte cheie: comunitate terapeutic, adicie, medi-cin holistic

Abstract:The Therapeutic Community, even if established

from many decades and recognized in many countries as the main link in the therapeutical chain of disorders as the addiction to legal and illegal drugs, is still a pioneer model in Romania. In its special therapeutic field the doctor-patient relationship has certain particularities, the therapeutical process being influenced mainly by the group dynamic. The approach is a holistic one, including beneath the classical medicine the group and individual therapy, family counselling, ergotherapy and the training of social skills.

Key words: therapeutic community, addiction, holistic medicine

Concepia de comunitate terapeutic a fost dezvoltat de ctre psihiatrul britanic Wilfred R. Bion, asociat grupului Tavistock, care a nceput s trateze, n aa numitul experiment Northfield, veterani suferind de nevroze n urma experienelor din rzboi, n cadrul unor edine de grup n loc de psihanaliz individual, pentru a putea beneficia de metodele psihanalizei un numr mai mare de pacieni.

Termenul comunitate terapeutic a fost consacrat n 1946 de ctre Tom Main, care a aplicat aceast concepie la Cassel-Hospital lng Londra. Este vorba de o restructurare a situaiei clinice, astfel nct aceasta, sub forma comunitii terapeutice s poat sprijini procesul terapeutic, spre deosebire de mediul patogen n care persoana respectiv a trit anterior. n aceast concepie toi oamenii care triesc i muncesc mpreun ntr-un centru psihiatric, respectiv pacienii, surorile, infirmierii, medicii

i personalul auxiliar, fiind legai de relaii bazate pe o ncredere reciproc autentic, formeaz o unitate organic cu elul de a crea cele mai bune premize pentru vindecarea i reintegrarea n viaa social.

n acest model pacienii nu mai au rolul unui membru pasiv, care doar primete o asisten i este dependent de instituie, ci devine un participant activ i partener n aplicarea planului terapeutic i chiar un membru deplin i un colaborator n comunitatea clinicii.

Pacienii particip la toate activitile din cadrul centrului, primesc mai mult responsabilitate i mai multe posibiliti de a participa la luarea deciziilor, sunt tratai ca parteneri. Pot primi diferite sarcini n cadrul clinicii. De exemplu, unii se ocup de flori, alii de programul pentru timpul liber, alii primesc sectoare unde rspund de ordine i curenie, sau rspund de respectarea programului de ctre toi pacienii. Pot deveni nai pentru pacienii noi, i familarizeaz cu regulile casei, i ajut s se integreze. Pot fi alei responsabili de cas sau de echipe. Se pot ocupa de distribuirea corespondenei.

Cteva principii fundamentale ale unei comuniti terapeutice sunt:

1. Clinica este un cmp terapeuticn clinic devine activ un cmp terapeutic iar procesul

terapeutic este influenat mai ales de situaia i dinamica grupului. Relaia dual medic-pacient, respectiv terapeut-client, trece pe un plan secundar. Psihoterapia nu este limitat la terapia individual efectuat cu medicul sau psihologul.

2.Terapia este asigurat printr-un grup de persoane active n terapie

Cmpul terapeutic poate fi meninut doar printr-o colaborare strns i o bun coordonare n cadrul grupului. Asta presupune o comunicare ct mai deschis ntre toi participanii i o mare toleran fa de toi membrii. Este important continuitatea echipei de terapeui. Este valabil principiul stimulrii optimale a funciilor i capacitilor fiecrui membru pornind de la premiza egalitii tuturor membrilor.

3. Potenialul terapeutic al pacienilor este susinut n mod optimal

Pacienii particip n mod activ i responsabil la procesul terapeutic, pentru a-i crete autonomia. Fiecare este ncurajat s se prezinte n cadrul comunitii, pentru a putea profita de feedbackul celorlali i a-i putea corecta tiparele necorespunztoare. Sunt ncurajate aciunile concrete, pentru a facilita accesul diagnostic i terapeutic. Tot ce se ntmpl n cadrul comunitii terapeutice poate fi inclus n reflectri i evaluari. Chiar i realitatea pacientului din afara clinicii (de exemplu profesie, familie) sunt incluse n terapie.

RELAIA MEDIC-PACIENT N CADRUL UNEICOMUNITI TERAPEUTICE

Dr. Lux Holger Ortwin, Sibiu-ura Mic

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Trecnd acum la experiena direct dobndit n peste zece ani de activitate n cadrul Comunitii Terapeutice Nazaret din ura Mic (pentru brbai) i fiind implicat n unele perioade i n acordarea asistenei la Comunitatea Terapeutic Insula Speranei din Vurpr (pentru femei), ambele patronate de Asociaia umanitar Crucea Albastr din Romnia, doresc s punctez cteva aspecte eseniale ale procesului terapeutic ntr-o comunitate terapeutic pentru persoane dependente de alcool sau alte droguri, aflate n recuperare.

Foarte important este momentul stabilirii primului contact, care se poate realiza pe cele mai diverse ci. De multe ori este pe cale telefonic, alteori prin scrisori sau vizite. Uneori suntem solicitai direct de ctre persoana dependent, dar n cele mai multe cazuri cei care sun sunt membrii de familie, rude, prieteni etc. . Se pune deci problema transmiterii unor informaii corecte ntr-o form succint i totui amabil. De multe ori sunt pacieni care rspund prima dat la telefon i intermediaz legtura cu terapeuii. Deci i ei sunt inclui n acest proces, fiind instruii n privina informaiilor pe care le pot transmite. Persoanele care ne caut au informaii sau reprezentri foarte diferite despre o comunitate terapeutic Uneori au informaii din mass-media, alteori de la medici, psihologi, asisteni sociali sau preoi cu care colaborm. n ultimii doi ani muli au aflat de existena noastr prin internet.

Pasul urmtor este o consiliere cu persoana dependent sau cu aparintorii care doresc s ia legtura cu noi. Ideal este ca aceast consiliere s se realizeze att mpreun ct i separat, pentru a permite o evaluare ct mai complex a situaiei. Dac distanele sunt mari i persoanele n cauz nu au posibilitatea s se deplaseze, uneori aceast consiliere se rezum la o convorbire telefonic. Acolo unde este posibil consilierea familiei va continua i pe perioada terapiei persoanei dependente i chiar i dup aceea, pentru a reduce comportamentele co-dependente i a prelucra greelile care se fac frecvent din partea familiei: reprouri inutile, nencredere exagerat, teama de a-i transfera responsabilitatea, dezinteres fa de noile preocupri, ateptarea unei atitudini servile din partea celui dependent etc.

Evalund datele obinute, stabilim dac este vorba i de o dependen fizic, respectiv dac exist riscul de apariie a sevrajului la ntreruperea consumului. Dac este cazul, recomandm o internare de 1-2 sptmni la un spital de psihiatrie pentru dezintoxicare. Dar ne ntlnim i cu cazuri care refuz internarea la psihiatrie. Atunci eventual i internm cu declaraie pe proprie rspundere vizavi de posibilele complicaii ale sevrajului. tiu ns i de comuniti terapeutice n alte ri unde chiar i dependenii de heroin sunt primii direct, trecnd prin sevraj pe viu (cold turkey), fr medicamente. La pacienii care prezint doar o dependen psihic nu se pune problema internrii prealabile la psihiatrie, dect eventual pentru o comorbiditate (depresii severe, tulburri anxioase).

Terapia propriu-zis ncepe cnd persoana este lucid i respect regula abstinenei, dealtfel condiia sine qua non a reabilitrii psiho-sociale.

Metoda principal este terapia de grup. Ea are multe avantaje n cazul persoanelor dependente. Stimuleaz

solidaritatea ntre persoane care au trecut prin experiena aceleiai boli. Grupul reduce din responsabilitatea terapeuilor pentru schimbrile care urmeaz s aibe loc i stimuleaz capacitatea de autovindecare (autoreglare organismic) a membrilor grupului. De asemenea n cadrul terapiei de grup se depete mai uor tendina de negare sau minimalizare a problemei din partea pacientului, care la nceput este adesea ruinat de comportamentul su anterior legat de dependen, sau care poate nc sper ca poate redeveni butor normal.

Omul poate afla n grup c nu este singur cu suferina sa. Poate ctiga ncredere n sine, aflnd cum i-au rezolvat alii problemele pas cu pas, alii care poate au avut o situaie la plecare i mai grea. Primete feedback la modul cum este perceput n cadrul grupului i poate experimenta, n acest cadru, noi modele de comportament. Adesea este perceput n mod pozitiv sentimentul apartenenei la un grup, uneori dup perioade lungi de (auto)izolare. i prin observarea celorlali i rezonan cu emoiile lor poate s neleag mai bine cum funcioneaz propriul psihic i poate nva i din experiena celorlali. Poate s-i creasc ncrederea de sine, observnd c este important pentru ceilali i c poate s-i ajute. Cteodat se formeaz n grup relaii aa cum existau ele in familia n care a crescut. Atunci acestea pot fi prelucrate n grup. Prin exprimarea i trirea sentimentelor n grup poate ctiga mai mult ncredere n propriile sentimente. i, n sfrit, poate ajunge la concluzia c el este rspunztor pentru viaa sa i pentru sensul pe care i-l d. ns toi aceti factori de interaciune din cadrul grupului nu-i pot exercita efectul pozitiv dect cu condiia ca persoana respectiv s devin activ. (2)

Desigur c i n cadrul comunitii terapeutice terapia individual i pstreaz valoarea ei. Mai ales pentru abordarea anumitor probleme pe care pacientul le consider prea intime pentru a le aduce n faa grupului. Am remarcat c solicitrile de terapie individual sunt foarte diferite, ceea ce ine n mare parte de personalitatea fiecrui pacient.

Foarte important n cadrul comunitii terapeutice este i ergoterapia, sub diversele ei forme, de la munc comunitar la art-terapie. Rein o expresie a unor ergoterapeui francezi care ne-au vizitat n urm cu civa ani: n ergoterapie munca este pretext pentru terapie.

Andre Moreau o formuleaz n modul urmtor: Munca nu este un scop n sine, ci un mijloc de a-i dezvolta conduita n faa celorlali, de a observa, de a sublinia n ce msur un participant repet, aici i acum, tulburrile de comportament pe care le regret sau la ignor n exterior. (...) Pentru a crete eficiena, caut s gsesc activiti reale i nu imitaii cum ar fi mpletitul, macrameul sau pictura decorativ. Dimpotriv, caut sarcini ct mai obinuite posibil, simple, puin primitive ca s le fac accesibile tuturor, fr operaiuni tehnice complexe, fiind totui atent n special la utilitatea lor i la posibilitatea de a aprecia eficacitatea real a persoanelor: restaurarea unei case, activiti de terasare, zidrie, foraj, grdinrit, tierea lemnelor... (3)

i n comunitatea noastr terapeutic pacienii sunt implicai mai ales n activiti cu utilitate practic: grdinrit, ngrijirea unor animale, lucrri de ntreinere i

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amenajare a cldirilor, repararea de biciclete second-hand, producia de suc natural de mere, buctrie etc.

elul terapiei pentru pacienii aflai ntr-o terapie de reabilitare pentru o adicie poate fi formulat n cuvintele: O via responsabil, mplinit, fr drog.

Fritz Perls, printele Gestalt-terapiei, i-a formulat elul n modul urmtor: Omul modern a pierdut att de mult din potenialul su, nct capacitatea sa de a face fa existenei este mult diminuat. elul meu este urmtorul: Pacientul s-i recapete potenialul pierdut. S integreze polaritile aflate n opoziie, s recunoasc diferena ntre jocurile sale mai ales verbale i comportamentul su autentic (...). n criza desfurat ntr-un mediu sigur, al situaiei terapeutice, pacientul ncepe s-i asume riscuri i s-i transforme energiile. n loc s-i manipuleze mediul pentru a obine sprijin se urmrete obinerea unui autosuport ct mai mare, deci ncrederea n propriile resurse. Acest proces este numit maturizare. Cnd pacientul a nvat s stea pe propriile picioare din punct de vedere emoional, intelectual, i economic, va disprea nevoia sa de terapie. Se va trezi din comarul existenei sale. Tehnica de baz este nu s explicm pacientului cum stau lucrurile, ci s-i punem la dispoziie posibilitile s se neleag singur i s se descopere. n acest sens, influenez i frustrez pacientul nct se vede pus fa n fa cu sine nsui. n acest proces se identific cu potenialul su pierdut, de exemplu asimilndu-i proieciile sau eliminnd prile strine. (4)

Mai ales n ultima parte a terapiei, n comunitatea noastr terapeutic, punem accentul pe nsuirea unor tehnici i metode pentru prevenirea recidivei (pstrarea distanei de siguran, fixarea de eluri pozitive, autoevaluare realist, trecerea la aciune, creterea toleranei la frustrare, exersarea pe uscat a situaiilor cu risc de recdere), innd cont de situaia specific a fiecrui client.

Pentru muli dintre clienii notri primul an de abstinen este greu de suportat. Poate c pe plan raional sunt convini de avantajele noului stil de via, bazat pe

abstinen. Dar pe plan afectiv nc nu simt un echilibru. i poate nc nu au nvat foarte bine s se bucure de alte plceri ale vieii.

Un prieten american, abstinent de alcool de peste 20 de ani, mi-a spus odat: Nu tiu dac am avut cinci zile bune n primul meu an de abstinen. Dar n ultimul an nu tiu dac am avut cinci zile proaste.

Doresc s nchei cu nite cuvinte care n opinia mea se potrivesc deopotriv att comunitii terapeutice ct i grupului Balint:

Ne aflm aici pentru c nu putem scpa de noi nine. Att timp ct omul nu se poate privi pe el nsui n ochii i inimile semenilor si, el se afl ntr-o continu evadare.

Ct vreme nu accept ca cei din jur s fie prtai ai interiorului su, el nu are parte de adpost.

Ct vreme se teme sa fie neles, el nu se poate recunoate va rmne singur.

Unde putem afla o asemenea oglind dac nu n aproapele nostru?

Aici, n comunitate, omul poate s i clarifice anumite lucruri despre sine i nu se va mai vedea uriaul viselor sale sau piticul temerilor sale, ci omul parte a unui ntreg care i aduce contribuia la propria prosperitate. Pe un astfel de teren poate prinde rdcini i poate crete, nu singur ca n moarte, ci viu ca om ntre oameni.

Richard Beauvais (1964)

BIBLIOGRAFIE

1. Franz Sedlack, Gisela Gerber: Beziehung als Therapie, Therapie als Beziehung. Michael Balints Beitrag zur heilenden Begegnung, Mnchen, 1992

2. Ralf Schneider, Ingrid Lux, Holger Lux Alcoolul i medicamentele droguri? Editura hora, Sibiu, 1999

3. Andre Moreau Viaa mea aici i acum Gestalt-terapia, drumul vieiiEditura Trei, Bucureti, 2005

4. Stefan Blankertz, Erhard Doubrawa Lexikon der Gestalttherapie, Peter Hammer Verlag, Wuppertal, 2005

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THE IMPORTANCE OF STRONG WORKING ALLIANCES IN BALINTGROUP DEVELOPMENT*

Richard B. Addison, PhD. U.S.A

Abstract:In order for Balint work to flourish, leaders need to

actively develop new groups and sustain those groups over time. It is not enough to be an accomplished Balint leader. Balint leaders must attend to the development and maintenance of good working alliances. These must include relationships with individuals, groups, and the organizations within which these groups take place. This paper examines the working alliances in three Balint groups: for physicians in training, faculty physicians, and physicians in a large medical practice. The future of Balint work depends on developing and maintaining solid, dynamic and successful multilevel working alliances.

Key words: group leader, relationship, future of Balint work

One of the passions in my professional life since Ive been at the Santa Rosa Family Medicine Residency over the last 27 years has been leading Balint groups and other reflective group experiences. One of the main reasons we have created the ABS, IBF, and other Balint societies, is the promotion and furtherance of Balint work. This includes both the expansion of Balint work to those not currently participating in groups, as well as the care and maintenance of those already existing groups. Unless we pay attention to how best to maintain the quality of the groups we are currently leading, develop new groups, Balint will not grow and flourish. This is a problem that weve been grappling with for a while.

The first part of my argument is that it is not enough to be an accomplished Balint leader; not only do we need to be excellent leaders, we need to actively work to develop new groups, and sustain those groups over time. (I wont continue on this point, as Im fairly confident I would only be preaching to the choir.)

And here is the second, and most central part of my argument and the one Ill be focusing on today the crucial importance of the working alliance for the future of Balint work.

There is a great deal of very good research coming out of psychotherapy that is quite germane to the purpose of promoting and sustaining productive groups. This body of research looks at the working alliance. A good strong working alliance is defined as the degree to which the therapy dyad is engaged in collaborative, purposive work. 1They find that the quality of the working alliance is by far the most predictive of a successful outcome in psychotherapy --more important than patient characteristics, psychotherapist characteristics, psychotherapist technique, attitudes or theoretical orientation. I believe that this is also the case in primary care medicine. And I believe it is also

the case in Balint groups. Therefore, what Im going to focus on today is an expansion of the definition of the working alliance to include not only physician and patient, not only leader and group, but also, and perhaps most importantly, leader and organization. I am arguing that the development and maintenance of a good working alliance must include relationships with individuals, groups, and the organizations within which these groups take place, in order to optimize the possibilities of successful, long-standing Balint groups.

To this end, Im briefly going to trace the developmental process and challenges of the three Balint groups I currently lead, highlighting the problems that arose, threats to the formation and continuance of the groups, and how I am addressing those problems, all with an eye to the importance of creating and maintaining good working alliances so that Balint group work can continue to grow.

FIRST I WILL TALK ABOUT RESIDENT BALINT GROUPS.

How did the Santa Rosa Resident Balint group experience come to its current form? We had resident groups about 25 years ago when FD came for an 8-year tenure as our residency director. When he left, the groups disappeared. The subsequent director (whose tenure was about 12 years) couldnt understand Balint (he stormed out of the room during one demonstration Balint). All this time, we had P&PD groups, which addressed many of the residents needs for support and group affiliation and were very popular. However, I kept looking for an opportunity to reinstitute resident Balint. It turned out the director of our outpatient family medicine center had participated in a previous Balint group and was willing to excuse R2s from clinic for one hour twice a month for a Balint experience. I remember attending a harvest party at his home after he told me that almost no faculty member ever attended any of his functions outside the residency. I think this helped our working alliance. He later told me that he had noticed that patient complaints decreased dramatically when residents began doing Balint. I told him how much I appreciated his creative problem solving that freed the R2s to form a Balint group. The group was well-liked and got very positive feedback on the year-end evaluation. This allowed me to think about expanding from a one-year experience for just R2s to a two-year experience that included R2s and R3s; In order to get the support from other faculty members to expand the group, I knew I had to rebuild the entire Balint infrastructure at the residency. By this time, I had the Faculty Balint Group going again. We also had the ABS credentialing initiative going strong. I encouraged a few other faculty members to attend Leadership Training Intensives and to become credentialed leaders. I also had

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been at the residency for 20 years and had developed good working relationships with most of the faculty. With this support among the faculty, I proposed taking over a precious dedicated conference hour twice a month, where residents got credit for attendance and did not have competing clinic pressures. Even though the residency director couldnt stand the Balint process and didnt understand it, we had a good enough relationship that he trusted my judgment that it would be a worthwhile educational experience for the residents. I had a similar relationship with the residency administrator, who, at a critical meeting, in the face of opposition to Balint, came up with the compromise idea of trying the Balint groups for a two-year trial. That was about 4 years ago.

Residents spend two years in Balint now, a year with each of two leader pairs, Two of the non-faculty leaders volunteer their time without pay, and one of whom drives over an hour twice a month to co-lead his group. In terms of maintaining the group, all leaders (including one trainee) meet after the groups for 30-45 minutes where we present our groups, and discuss group development, leadership, and threats to the group, co-leader relationships and other such issues.

The group takes place at the end of the day on Thursday, a time when most residents would rather be going home to their families or going out to exercise. The residents are required to sign in for Balint, just as they are required to sign in for all the other Thursday afternoon conferences.

As a member of the faculty who tries to attend to their well-being and long-term development, I hope the residents know I am there for them, that I try to understand how their lives as residents are not easy. I cut them slack if they are late for the start of group. I try to end on time, believing it is more likely that they will attend if they are confident

that we will be done on time. I try to understand when they use the group to complain about how difficult they have it with patients. I try to make the atmosphere of the group stimulating and energizing, especially since it takes place at the end of the day. I try to come to the group with a generous, optimistic attitude. I honestly look forward to spending time with the residents and their cases. (They love to hear updates on the cases previously presented, since many of them know the patients being presented by other residents.) I try to understand the stress they hold as residents at different developmental levels of their training.

(The beauty of a vertical group that contains residents who have never experienced Balint as well as residents who have a year of experience, is that the experienced residents help train up the inexperienced ones. The inexperienced ones look forward to being with the class ahead of them in the Balint group.) In other contexts, I mention that their difficult cases might be possible Balint presentations. I want them to graduate knowing what the Balint process is and to feel it as familiar, to miss it, and band together with their colleagues to request a Balint group from their employer. (More about this later.)

To summarize, in order to develop and maintain a successful Balint experience during Residency, I had and have to attend to my working alliances with the residency director, the family practice center director, the residency administrator, my co-leaders, the individual residents, and the organizational needs of the residency curriculum.

AND NOW THE FACULTY BALINT GROUP:

This is a group that began over 25 years ago, although only two of us were members back in the day. It had a long hiatus during very dark financial times. I reconstituted

Curs lideri

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the group about 8 years ago. In its current form, we meet twice a month. It is led by myself and another credentialed physician co-leader. The largest challenge for Faculty Balint is numbers; this group is always on the edge in terms of having enough members to make it feel like it is a solid group. It currently has five or six participant-members, plus the two leaders. Competing demands for faculty time always threaten having enough bodies in group to make for a lively discussion. I send the members reminders about a week in advance of the group, requesting regrets only, assuming they will attend. I also ask them to block their schedule for the second and fourth Thursday of each month from 3-4 PM. I invite them to invite new faculty, as I do; I emphasize the team building and connective benefits of group that they not only come for themselves, but they come to support each other as well. I try to look forward out loud at being able to spend reflective time with them at the group. We joke and have fun with each other, most of us believing that education, at best, should also be an enjoyable experience.

Cases come from either the members (or occasionally the leaders) patient or teaching population. Most everyone looks forward to presenting cases. The members are very considerate and tend to take turns doing so; it is rare that one person will dominate with frequent presentations. My co-leader and I meet briefly at the end of the day to check in about anything we need to attend to. I write up the case at the end of the day. I occasionally remind them of the patients and residents they have presented over the years.

My role is far less traditional in this group. Again, I struggle against scheduling threats to member attendance, such as faculty presentations at the resident conferences. (I have even asked the conference coordinator to try not to schedule faculty who are Faculty Balint participants to present during the time that Faculty Balint is held. Since he happens to be a member of Faculty Balint, this sometimes works.)

Unfortunately, the group is sometimes quite small: only three or four members plus two leaders on occasion. At these times, when the presenter pushes back, one or both of the leaders will participate more with the group in speculating about the case. Also, on occasion, both of the leaders have presented their own cases.

Most of the participants are my colleagues, some were my residents whom Ive recruited to be faculty, and recruited to be in the Faculty Balint group. They each take an hour out of their administrative time to attend. One is a former interim residency director who saved my job during dire financial cutbacks. So my relationship to the members of this group is much more complex and multidimensional than in the resident group; instead of being just a leader to the group members, I am also a colleague, former teacher, friend, and consultant to the members at various times.

The most striking difference in my leadership of the Faculty group is my (and my co-leaders) availability to fluidly participate in a member-like role, while still maintaining ultimate responsibility for the group.

Because of the size, the leaders move back and forth between member-like and leader-like interventions. This is sometime referred to as leading from within. 2 To not do so, would not fit with our Faculty Balint group. Over the years, Ive evolved to this style of leading the group, and it seems to work. Now if we can just secure the funds to hire additional faculty who want to part of the group

So again to summarize, for the ongoing success of the Faculty Balint group, I again have to attend to my working alliances with the residency director, my volunteer co-leader, the conference coordinator, the faculty members, and other faculty, who might become members at some time in the future.

BALINT FOR PRACTICING PHYSICIANS

I have just begun a group for physicians practicing in a local HMO. I co-lead this group with another credentialed leader, an MD, who also co-leads the other resident Balint group. The HMO group has about 9 possible attendees, five of whom usually can attend at any one group. The participants are primary care physicians, either family physicians or internists, who expressed interest in this group after I was invited to give a talk on burnout, meaning in medicine and sustainability of practice. I was invited by a graduate of the program who missed having a group reflective experience and wanted the HMO to institute one.

Primary care physicians in this organization were under tremendous stress. Some had left, many were depressed. They decided something was needed. The department planned a day off-site, part of which was my talk. At the end of the talk, I suggested possible actions both individuals and organizations might take to address the problem. I recommended Balint and P&PD groups as two important organizational interventions to address burnout and promote sustainability of practice. From that talk and their fear of an impending shortage of primary care physicians and concern for others becoming burned out, the HMO committed to three groups for a year, each meeting twice a month. Some physicians chose to attend the Balint Group, others chose the P&PD group, and a few are choosing both.

The participants include: newly hired physicians having difficulty acclimating to the HMO, since they receive the most difficult patients for the first two years until they have established their own, familiar patient panel; physicians who know me from another context either they were former residents I taught, or physicians who had been at one of my talks or workshops; physicians who had previous Balint experience; physicians who desperately needed to talk about troubling cases in a non-judgmental format; physicians who were isolated and wanted to connect with their colleagues; or physicians who were on the edge of quitting or falling apart.

I still think it an unbelievably propitious opportunity to run such a group for such a productivity-driven organization. At a time when physicians in such an organization come under scrutiny for ordering more tests and lab work than

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their peers, when physicians are asked to see more and more patients, for physicians who are inundated with charting and other desk medicine requirements, I think it somewhat extraordinary that the organization is willing to pay for two leaders to hold a Balint group for interested physicians, and, that physicians are willing to take an hour out of their busy day (which will likely result in them working an hour later that evening). It seems in this local context a type of tipping point was reached allowing everything to come together so that the group could begin and people could experience the benefits.

Because of the relationship many of them have had with me over the years when they were residents, they trust that a confidential group reflective experience might again be helpful to them. One of them missed his group experience so much that he asked me to give the talk, and asked the HMO to institute the groups for the physicians. Without the good working alliance he and I had developed during his residency, Im not sure either the opportunity to speak to the department or the opportunity to lead groups for the HMO would have occurred.

The largest difference in my leadership of this group is probably my intense efforts at establishing the safety of the group in the face of constant threats to that safety: For example, the group felt threatened that the department chair wanted to participate, since he evaluated them and granted them their end of year bonuses. Also, there is no dedicated room for this group, except for one that contains the refrigerator and microwave that other staff use for their lunches. Even though I place a sign on the door asking them to wait until the group is over (a somewhat unrealistic request on my part), we are often interrupted by someone needing something from the refrigerator. Also the room is separated from the health educators office by

an accordion divider, which is unsatisfactory in terms of confidentiality. For the small price of a sandwich and soft drink, the health educator has offered to lunch elsewhere and try to schedule appointments around our group time. I want the members to feel safe presenting cases of great vulnerability in a confidential format. The tremendously painful cases they present (e.g., a frustrated physician presented his relationship with an eating disordered patient refusing all entreaties to eat; a shocked and surprised physician presented one of his patients, who worked at the medical center, who carefully and privately planned her own successful suicide; and others) These are evidence that they can allow themselves to share very vulnerable feelings and situations with each other.

I promised to supply the HMO with a group evaluation by the group members in the late fall. I dont know if the HMO will be able to afford or choose to continue the group past the end of the year (or even to the end of the year, considering the current economic challenges). So far the participants have been incredibly enthusiastic and appreciative of the opportunity. I hope the organization will find the resources so that the group can continue.

To summarize for the practicing physician group, I had and have to attend to nurturing strong working alliances with former residents, the department chief (and his administrative assistant who arranges the rooms and the lunches), as well as the individual physicians in the group. As the year comes to a close, I imagine my working alliances with others will also become important in regard to the potential continuation of the group.

In conclusion, I am convinced that without the good relationships or working alliances that I developed over the years, with individuals, with the groups, and with organizations, the continued existence and the ongoing viability of all of these groups would not be possible.

I hope that these three tales will stimulate you to go out and examine the nature and quality of the working alliances you have now; I also hope you will look at potential alliances that may either positively affect the longevity of your existing groups or open up the possibilities of new groups. I hope that attention to the quality and strength of working alliances at all levels will only help us to further promote Balint work, work that we all have experienced as invaluable in improving the physician-patient relationship, the health and well-being of patients, and the satisfaction, sustainability and meaning of medical practice.

References:1. Baldwin S, Wampld B, Imel Z. Untangling the Alliance-

Outcome Correlation: Exploring the Relative Importance of Therapist and Patient Variability in the Alliance. Journal of Consulting and Clinical Psychology 2007;75:842-52.

2. Kerfoot K. Leadership: Social Identity and Guiding from Within. Nursing Economic$ 2007;25:296-8.

* This paper was presented on April 18, 2009, International Balint Weekend, Chicago,

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PIERDEREA I DOLIUL LA PACIENII ONCOLOGICII FAMILIILE ACESTORA

Dr. M Psih. clinician specialist dr. Ioana OMER,Spitalul de bolnavi cronici i geriatrie Sf. Luca, Bucureti

Rezumat:Pierderea i doliul sunt etape pe care pacienii

oncologici i familiile lor le parcurg de la debutul bolii. n cazul pacienilor adaptarea la pierdere este condiionat de vrsta pacienilor, stadiul bolii, structura de personalitate a acestora, copingul la boal. Reaciile la pierdere ale pacienilor pot fi de tipul: negare, furie, dezorganizare, acceptare, reorganizare, prelucrarea durerii i emoiilor, reorientarea ctre alte aspecte ale vieii. n cazul familiilor reaciile pot fi asemntoare cu cele ale pacienilor i ele sunt influenate de: natura relaiei cu persoana disprut; (persoan apropiat sau nu, relaii armonioase/conflictuale, etc.), personalitatea supravieuitorului. Att n cazul pacienilor ct i n cazul familiilor se poate recurge la consiliere, psihoterapie, grupuri de suport, etc.

Cuvinte cheie: modaliti de ajutor reacii, psihoterapie.

Abstract:The bereavement and the mourning are two important

stages for the oncological patients and their families since the beginning of the disease. In the case of the patients the adjustment to bereavement it depends from the age, stage of the disease, their personality, coping with the disease. There can be different reactions to loss of the patients: negation, anger, and despair, and disorganization, acceptance, processing of the pain and emotions, reorientation to other life aspects. The reactions can be similar in the case of the

patients families and are influenced by different aspects: the nature of the relationship with the patient (good or bad relationships), the personality of the survivor. There can be used different modalities of help like counseling, psychotherapy, support groups, etc.

Key words: Modalities of help, reactions, psycho-terapy:

Pierderea (englez = loss) definete situaia unei persoane care a suferit o desprire de o alt persoan de care era ataat (1). Pierderile pot fi ns n cazul bolnavilor neoplazici de mai multe tipuri dup cum vom vedea n continuare.

Dup debutul bolii, pacienii cu cancer se pot confrunta cu mai multe tipuri de pierderi care pot avea consecine negative asupra evoluiei lor ulterioare cu rsunet n plan psihic sau fizic. Acestea pot fi (2):

1. Pierderea sntii (n sensul de a fi bine, a se simi bine);

2. Pierderea independenei: de multe ori pacienii oncologici devin dependeni de ngrijirile care li se acord de ctre cei din jur, mai ales, n cazurile complicate sau stadiile terminale;

3. Pierderea unor pri din propriul trup (mastectomii sau extirpri chirurgicale ale anumitor zone afectate de cancer);

4. Pierderea sexualitii: se leag de credina pacienilor c nu mai pot funciona sexual la fel ca nainte

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dei cercetrile au artat c n multe cazuri extirprile tumorilor din zonele genitale nu afecteaz dorina sexual i nici buna desfurare a actului sexual;

5. Pierderea viitorului: n cazul bolnavilor de cancer o serie de planuri de viitor i de sperane sunt distruse. Pacienii sunt confruntai cu contiina faptului c viitorul este anulat.

6. Pierderea speranei: este cea mai chinuitoare dintre multiplele i zdrobitoarele pierderi. G.N. Shrader (1992, apud (2)) observ sentimentele de disperare, neputin i dispariie la cei atini de boli incurabile, iar L. Dean i colab. (1998, apud (2)) noteaz faptul c ei exprim dezamgire i demoralizare. Privind ctre viitor rareori pacienii viseaz la remediu i la vindecare, ntruct i pierd motivaia pentru via i capacitatea de a face planuri;

7. Pierderea securitii psihosociale: bolnavii de cancer resimt insatisfacie,

nesiguran, insecuritate, dezamgire i constrngere n redefinirea valorilor pe care nc le mai au (K.A.Coburn, D.Malena, 1998, apud (2));

8. Pierderea interesului pentru via;9. Pierderea statutului social i a rolurilor sociale:

att a celor profesionale, ct i a celor social-ceteneti sau familiale;

10. Pierderi materiale: pierderea locului de munc i implicit a venitului rezultat din aceasta pentru unii dintre ei;

11. Pierderea stimei i a respectului de sine: respectul de sine se leag de imaginea de sine pe care o are pacientul. n formarea imaginii de sine intervin o serie de factori precum aspectul fizic, inteligena, caracterul, capacitatea de a munci, de a fi productiv, capacitatea de a gsi mijloace compensatorii pentru o deficien real etc. i care, de multe ori, n afeciunile oncologice sunt alterai provocnd apariia unor stri de deprimare i dezamgire.

Reaciile de doliu la pacienii oncologici consecutiv acestor pierderi sunt descrise de ctre E. Kubler-Ross (1969) care a identificat 5 etape/stadii pe care le parcurge pacientul din momentul contientizrii bolii:

I. Prima etap este numit de autoare ocul i negarea: etapa Nu, nu eu/ Nu e posibil/ Nu mi se poate ntmpla tocmai mie. Negarea este considerat un mecanism psihologic-tampon, un mijloc de a face fa unor veti ocante prin amnarea realitii.

n aceast etap, terapeutul trebuie: s nu insiste ca pacientul s accepte realitatea diagnosticului, s evite s-i dea sperane false, s-i acorde timp i sprijin emoional pentru a accepta situaia i s fac mici sugestii n direcia adevrului. Negarea poate fi acceptat ns doar atta timp ct nu afecteaz pe de o parte deciziile medicului n diversele etape ale bolii, nelegerea obiectivelor tratamentului de ctre pacient i discernerea ntre diversele opiuni terapeutice, iar pe de alt parte, demnitatea i respectul de sine al pacientului.

II. A doua etap este Mnia/ furia (etapa De ce tocmai eu?/ De ce tocmai mie?)

Mnia poate fi ndreptat spre sine, spre supravieuitori sau spre Dumnezeu (pierderea credinei). De aceea, n aceast etap terapeutul trebuie: s dea posibilitatea

pacientului s-i exprime mnia i revolta; s nu fie critic i defensiv dac furia este ndreptat mpotriva lui; s descopere sentimentele reale, mascate de mnie ale pacientului.

III. A treia etap Negocierea (etapa Da, eu, dar) exprim acceptarea ideii morii dar negocierea pentru a mai tri puin. Aceast etap apare n momentul n care bolnavul incurabil renun la reaciile sale de furie n favoarea adoptrii unei conduite care ar putea prelungi ct mai mult perioada de timp rmas pn n momentul morii.

n aceast etap, terapeutul trebuie s accepte negocierea ca pe o reacie fireasc i s aib o atitudine de ateptare pentru a vedea ce se va ntmpla n continuare.

IV. A patra etap Depresia: (etapa Da, eu) este o reacie obinuit i de neles, i este nsoit de recunoaterea faptului c urmeaz actul final al morii. Pacienii sunt cuprini de sentimente de dezndejde i disperare, i devin adesea retrai i izolai.

V. Ultima etap Acceptarea/ resemnarea (etapa Da) este o etap n care terapeutul i pacientul trebuie s gseasc mpreun soluii la diferitele probleme ce apar pe parcursul evoluiei bolii.

Emoiile pacientului pot fi privite i ca un mozaic personal, prin intermediul cruia el rspunde ntr-un mod care i este caracteristic la situaia de boal, putnd manifesta -spre deosebire de modelul anterior- unele emoii simultan, astfel (4):

1. stadiul iniial: Fa n fa cu ameninarean acest stadiu pacientul poate trece printr-o serie de emoii

cum ar fi: frica, ocul, negarea, umorul, mnia, vinovia, anxietatea, ndoiala, negocierea, sperana, disperarea. Acestea pot fi prezente n totalitate sau doar unele dintre ele.

2. stadiul cronic: Contientizarea i recunoaterea prezenei bolii.

n stadiul cronic are loc diminuarea n intensitate a tuturor emoiilor din stadiul iniial i poate aprea frecvent depresia ca urmare a contientizrii i acceptrii situaiei n care se afl pacientul.

3. stadiul final: Acceptarea este definit prin acceptarea morii de ctre pacient.

Dup ali autori durerea consecutiv pierderii implic cteva faze: stupoare; dor i furie; dezorganizare; disperare; reorganizare (1,5).

J. W. Worden (1992) se refer la scopurile jelirii identificnd: acceptarea realitii pierderii; trecerea prin durere; adaptarea la noua realitate fr persoana decedat; reaezarea emoional a persoanei decedate n universul interior al supravieuitorului i reinvestirea n alte relaii.

J. Culberg (1978) identific urmtoarele faze: ocul, reaciile la oc (depresie, anxietate, disperare), prelucrarea durerii i emoiilor, reorientarea ctre alte aspecte ale vieii.

Din experiena clinic pot afirma c doar o parte dintre pacieni traverseaz toate aceste stadii, marea majoritate devin depresivi ntr-o prim faz, ulterior acceptnd realitatea diagnosticului i implicndu-se n tratament. O mic parte dintre pacieni intr ntr-o faz de negare i caut ali terapeui care s le infirme acest diagnostic sau

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acestora ntruct solicitrile crora trebuie s le fac fa familiile pot fi uneori la fel de mari ca ale pacienilor.

Membrii familiei bolnavului pot trece prin faze de evoluie similare celor trite de pacient n cursul bolii: ocul i negarea, furia/mnia, negocierea, depresia, acceptarea i resemnarea (8). Rudele apropiate sufer adesea de sentimente de vinovie i de eec, stadiile prin care trece familia dup aflarea diagnosticului fiind: stare de oc cu sentimente de culpabilitate, dezolare, disperare dup care urmeaz o faz de cutare de soluii i o stare durabil de echilibru (9).

Din experiena mea clinic de pn acum familiile dezvolt mai des tulburri depresive cu manifestri clinice (tristee, plns facil, inapeten, insomnii, sentimente de culpabilitate, etc.) sau mascate sub forma somatizrilor (modificri de ritm cardiac, crize de hipertensiune arterial, probleme de tranzit intestinal, probleme digestive, etc.).

Reacia de doliu reprezint de fapt reacia psihologic i emoional fa de pierdere, ecoul subiectiv al acesteia, ea depinznd att de natura pierderii, de trsturile de personalitate i copingul celui care sufer pierderea dar i de reeaua de suport social de care acesta dispune.

Reacia normal de doliu se manifest prin contientizarea dureroas a pierderii definitive, accese de disperare, plns, suspin, cutarea persoanei pierdute, rememorri ale unor momente din trecut, idealizarea persoanei i relaiei (9). Simptomele care pot apare n perioada urmtoare sunt: tristee, apatie, gnduri obsesive, iluzii, halucinaii hipnagogice, vise semnificative, tulburarea n facsimil (copierea acuzelor somatice ale decedatului) (5).Ulterior are loc o revizuire a concepiilor, modelelor interioare i rolurilor. Are loc o remaniere a personalitii prin adoptarea unor noi roluri, reorganizarea planurilor de viitor, modificarea statutului, a raporturilor de putere i control n familie.

apeleaz la terapeui specialiti n medicin complementar care le promit vindecarea.

n cazul pacienilor oncologici pierderile pot fi permanente (amputaii de sn, de colon, etc.) sau temporare (cderea prului, retragerea temporar din via social i profesional pe parcursul tratamentelor, etc.). Reaciile la pierderi variaz n funcie de vrsta pacienilor, stadiul bolii, structura de personalitate a acestora, capacitatea de coping la boal. Astfel, pacienii tineri accept mai greu pierderile mai ales dac au familii, sunt activi social i fac parte dintr-o reea dens de statute i roluri sociale. De asemenea, n stadiile curabile pierderile sunt mai uor acceptate dac pacienii contientizeaz faptul c aceste pierderi sunt eseniale pentru supravieuire. La pacienii terminali atunci cnd acetia i dau seama de ireversbilitatea bolii pierderile sunt de regul nsoite de disperare, depresie i deprimare. Pacienii cu personaliti echilibrate i mobilizeaz mai facil resursele interioare pentru a face fa bolii, n schimb cei cu structuri de personalitate labile, anxioase, hipocondriace pot dezvolta tulburri psihopatologice care necesit tratament psihiatric.

n fazele terminale la pacieni poate aprea frica (ce se va ntmpla dup, frica de a merge n iad, teama de a fi ngropat ntr-un loc ntunecos, etc.), retragerea i izolarea (mai ales n cazul pacienilor cu tonus fizic i psihic foarte sczut pentru care vizitele familiei i prietenilor pot fi obositoare, n acest caz respectndu-se dorina pacientului de a fi nsoit n aceste momente doar de persoanele pe care le vrea alturi) sau poate exista o perioad de profund luciditate n care pacientul este contient de ceea ce se ntmpl n jur, vorbete cu scop i neles, i ia la revedere de la persoanele dragi.

n ceea ce privete problematica psihologic a familiilor pacienilor oncologici, studiile efectuate au relevat aspecte interesante din punctul de vedere al evoluiei psihologice a

Dans din Oa

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