Tuesday, November 1, 2016

Daniel Kuhn Interview: surgeons, PTSD, Stress and Comfort zones

Daniel Kuhn Interview: surgeons, PTSD, Stress and Comfort zones:
          General Surgery News recently published a piece titled “When a Stressful Event Sticks Traumatic Stress Disorders Can Plague Surgeons; Psychiatrist Describes Technique Helpful in Erasing Ill Effects “ (an interview with Daniel Kuhn, psychiatrist) http://www.generalsurgerynews.com/In-the-News/Article/10-16/When-a-Stressful-Event-Sticks/38146/ses=ogst?enl=true. The topic meshes well with other discussion I have had on physician/surgeon resiliency (http://crisislead.blogspot.com/2016/08/lessons-on-resilience-and-burnoutdr.html).
       In this editorial Dr. Kuhn, a Psychiatrist in New York city, N.Y. developed a method that reportedly can readily clear PTSD and traumatic stress in one to two sessions in most cases.  He reports that when the Yom Kippur war erupted in Israel he returned home to serve as a physician in the Israeli Army. It was in this role that he detected a pattern amongst those who suffered from mental trauma in the battlefield and consequently developed his technique which allowed the patient to erase the charge of the recording of a traumatic event.
          He realized that the negatively charged image of a traumatic experience is stuck like a splinter in one's memory and continues to interfere and even overpower the individual, dictating attitudes, emotions and actions which are derived from the reality of the traumatic experience. The individual is transfixed to and  hypnotized by the traumatic experience. It induce intrusive recollections, bad dreams, avoidant anxiety etc. which  compromise his function, judgment and wellbeing.
Dr. Kuhn describes his technique as deconditioning which erases the charge of the traumatic memory by repeating many times verbal commands or using visualization technique. It is a new paradigm for treating PTSD, that by-passes the need for medications and regular psychotherapy. It is a form of a guided self therapy. It usually produces immediate release and lasting results.
He notes that as a cellist he was looking to enhance his own (as well as other's) performance level and found out that the Kuhn Technique helps to recover, improve and sustain peak professional performance level.
               Dr. Kuhn states that he has helped numerous Surgeons who suffer from a post traumatic stress. He notes that he has treated surgeons who experienced moments of acute stress  and overwhelm while  facing life endangering situations in surgery i.e. like laceration of a major blood vessel in a laparoscopic surgery, or who reacted negatively to being invalidated, humiliated or bullied professionally during residency training.
               Surgeons face stressful conditions and unpredictability on a frequent basis. In his book Forgive and Remember, Bosk, describes the difficulties in a Surgeon’s professional life in handling failure. Essentially our patients and peers (and us) expect surgery to be a quick fix compared to medical therapy of disease. When the outcome is not perfect doubt begins to creep in. If the surgeon does not elicit help or find a solution to break the cycle, then inevitably, performance will be negatively affected. At the ACS NSQIP conference (see Oct 2016Bulletin ACS), Peter Angelos is reported as stating "healing cannot occur without actions that would be illegal in any other context. It is an intensely physical relationship." This intensity likely makes failure extremely difficult to face if one is either not equipped to do so or they are becoming less resilient. At this same conference, Julie Freischlag presented a keynote address on resilience and noted that "despite our best efforts, someone is going to return to the hospital and as a surgeon, you need to generate ways to bounce up".  Diminished resiliency inevitably results in burnout.
             Several recent studies have highlighted the risk for PTSD in Trauma Surgeons and Surgical trainees (Journal of Trauma and Acute Care Surgery 2014;77:148-154;  Surgeon 2015. pii: S1479-666X[15]00099-2). Surgical trainees have been shown to have higher rates of psychological distress than the general population (10% reported PTSD symptoms lasting more than one month). In the Journal of Trauma and Acute Care Surgery Study  40% of trauma surgeons relayed symptoms of PTSD (15% met the diagnostic criteria for PTSD). This risk was increased with the following factors:
.Male trauma surgeons operating on more than 15 cases per month
.more than seven call duties per month
.less than four hours of relaxation per day

       Back in Dec 2015 Carol-Ann Moulton and I discussed a paper their Toronto group published in the Annals of Surgery on Comfort Zones and Risk Taking in Surgery (Taking a chance or playing it safe: reframing risk assessment within the surgeon’s comfort zone. Ann Surg. 2015); Details of that conversation are at http://crisislead.blogspot.com/2016/10/interview-with-carol-anne-moulton.html. In our discussion of the interviews which led to their publication it appeared that even the boldest appearing surgeons probably have a breaking point.  It is likely that every surgeon has a perception of where their boundary is; the place where they no longer feel comfortable.  Self-assessment literature seems to indicate that we frequently do not openly acknowledge that we have a comfort zone (or may not accept that personally). It may be that the temperamental and angry affect we see in some surgeons is actually a reflection of anxiety. It is unlikely that anyone is immune, but we simply do not discuss it.
                 I was fortunate to speak with Dan Kuhn about this process- why is it we have a risk of becoming too hesitant, too risk aversive, and in some cases frightened to operate as many surgeons have related?

How much a risk do Surgeons face for developing what you equate to PTSD?              
           “Most surgeons think their stress is related to a recent trauma, but in actuality it begins much earlier in life. Most of us apparently have a traumatic event early in training- a death, a difficult encounter with a mentor, colleague, training program…. A lot has to do with how we are trained- our education. Punitive drilling, like the Marine Corps, destroys your identity and can shatter you. Degradation and invalidation does not build the frame for one’s own identity. You don’t want to break your children’s spirit. You cannot traumatize them.  You cannot invalidate people into performing. “
       “Surgeons work under a considerable level of pressure and often face unpredictable crises. A Surgeon must be well informed, well trained, and must be alert and analytical at all times during surgical procedures. When faced with unpredictable emergencies like sudden uncontrolled bleeding, patient's unexpected death, operating errors or consequential malpractice suits, etc., such experiences may have a lasting traumatic impact on them, leaving them with a negative experience and conclusions that can become morbid and destructive.
  It is not always possible to shield oneself from such an exposure and when traumatized, it is quite harder to erase the effect of trauma on one's life and health. Furthermore, earlier similar experiences tend to compound the traumatic effect. After having developed chronic anxiety and significant work related stress following exposure to a single or recurrent mental trauma, some surgeons may opt for early retirement or limit their activity.
  A traumatic fixation occurs following an unexpected, overwhelming and life threatening event which impinges on one's performance and composure, i.e. accidents, injury, or high randomness and loss of mental control. At that moment the analytical mind is momentarily frozen as the neo-cortex is overpowered by the Limbic system (the reptile brain's survival mode). facing danger one can go into a hyper-focus and a fight mode, and find a solution to the danger, but another one will frozen by fear, alarmed and disconnect - being in a momentary dissociative state (confusion, disorientation and a state of discontinuity.) The highly charged image of the traumatic experience is then fixated in memory and becomes the seed of a post traumatic condition.    
           Even if a solution was found a moment later, a traumatic experience has already being lodged in one's memory and starts to impinge on the individual; the charged emotions and negative identities within that image will surface from now on in situation reminding one of s traumatic event(s), hitting the individual with a hypnotic force. It will distract  and upset the individual and interfere with his ability to function.
        The post traumatic reactions comes from the 'reptile brain' within us, from the limbic system of the brain, which reacting to a perceived danger in an attempt to protect the organism from a survival threat and a perceived danger.
         The trauma has a hypnotic effect on the individual who is in a state of trance, where his attention is divided between the present time and the past incident. The individual is engulfed and trapped in the traumatic experience like a fish in a fish ball with perception of a way out. Alcohol and psychotropic medications may have a temporary, limited symptomatic relief but do not erase the fixated experience or change the course of the condition that tends often to worsen and become chronic. In most cases psychotherapy is not able to release the trauma fixation and resolve the condition.
     An individual is more prone to develop PTSD if he operates on an unfamiliar territory, lacking a real understanding and mastery of the necessary skills or techniques necessary to solve problems. An opera singer who does not master her voice will be more anxious and prone to traumatic stress regarding her performance. A misinformed or untrained surgeon may be more susceptible to it too. Furthermore, being hungry, tired, and jetlagged or overworked while operating, or being preoccupied with other problems in life such as litigations, divorce or fear of loss of loved ones.
                In addition, similar experiences earlier in one's life are most likely to be stirred up and energize the more recent trauma, a compounding effect that makes the individual more prone to dissociate and develop a post traumatic stress disorder."

How do you know if you have this PTSD syndrome?
“when you have PTSD you know you have PTSD. You recognize you are not the same. Your personality has changed. You become reticent. You are not liking to do things you used to enjoy. You avoid them and get anxiety. Some people dissociate. It is a dissociative condition- you are overwhelmed. BUT you can take control, but that moment is forever a part of your memory. Some result to alcohol, drugs,… For example, look at musicians. They start in music because they enjoyed it. Soon something causes them to not feel enjoyment anymore. Then they start drinking.

Can you do anything?          
 “You cannot get rid of those emotions easily, but you can. You must use visualization and images to reform that memory. I use the Kuhn Technique - A Trauma Deconditioning Paradigm. I can use three questions to get to the right specific incident. You have go to the original event. It could be at a very early age and have nothing to do with surgery. It could be at age 3. You were fixated on it and now trigger the trap later on.” “The treatment aims at locating the moment of traumatic impact and then to repeat verbally repetitive commands to erase the trauma and its negative component (identities) like the angry, fearful, overwhelmed, anxious, avoidant ones.
          It is important to go first to the first traumatic incident, evoke it and then discharge it's with repetitive commands.
         There is a similarity between erasing a mental trauma and erasing a computer file by a command with the key difference being that while the information and recollection of the incident stays the negative charge around it is dissipated. The discharging experience feels similar to deflating a pressured balloon.
              There is a wide spectrum of severity in PTSD cases; many normally functioning individuals experience chronic symptoms of PTSD and are able to function while having negative symptoms of it.
         In summary The Kuhn Technique is a form of self therapy which readily produces distinct results in most cases if correctly applied. Supervision by an experienced person is strongly recommended for better results. Its benefits are lasting and no negative effects have been observed over many years of applications on many hundreds of cases. The Effectiveness of the Technique comes from the observation that repetitive commands erase the recording of charged negative experiences.  Usually it takes one to two sessions to release a condition in most cases. The technique is also very helpful before going on stage to perform or when facing stressful situations. The number of repetitive commands can shift dramatically from one condition to another, and range from very few ones to many dozens of them. A specific process ends usually with a sense of mental release; breathing become deeper and attention becomes free.

What is the trigger?
“Typically, you have a traumatic event and either you feel invalidated and humiliated or others invalidate you or humiliate you. You may deal with life threatening problems daily and handle them all well. Maybe you failed and a patient died. Maybe someone was not nice in their response to your failure. Their comments can seem innocuous to them, but to you this could be a major incident. For example, when I gave a talk, someone will blatantly be rude and argumentative. Someone can call you a charlatan.  Maybe the incident that triggered it really did not seem that significant but it triggered an early memory.“

Why are doctors at such a high risk?
“Doctors are at high risk due to their identification as a Doctor. Their identity is so rigid; they cannot allow it to be broken… like the tin-man. If you are very rigid and do not feel anything, emotionless, with no empathy, mechanical, indifferent- you are actually using a defense mechanism – a type of dissociation.
If you keep your core being and are empathetic and can be connected, you can typically respond adaptively. You have to have “beingness”. Others move to an area where they don’t have to deal with people, patients. Others avoid the emotional aspect. They don’t worry about the supratentorial aspects of patient care. “
“if you have good technique, good knowledge and are sure of it, you are protected. But if you are not sure, you are susceptible. The army can work with you to assure you are not dissociated. You must send people to battle with personal ammunition. Betrayal can have an extremely negative effect. A bad atmosphere can cause a very negative emotional response. If you sense that someone is just waiting for you to make a mistake. For whatever reason, this is traumatic. If you know someone does not like you, the sense of betrayal is always prevalent. You are overly cautious. If you are confident and have not been betrayed, it will sharpen your career.“

Are any of us beyond hope?
“no! I can work with you for 20 minutes. I handled casualties in Israel and traumatic memories in soldiers and restore their faith. I can find the trigger and eliminate the fearfulness. Whatever is scaring you, it can be erased.“

Is there any familial risk?
 “Some people are more prone than others. Some are more histrionic. That can be biological. The real question is if you can control it. “

Daniel Kuhn, M.D., Board Certified Psychiatrist, 200 West 57th Street, Suite 1205.  New York, N.Y. 10019 Phone: (212) 315-1755; Cell: (646) 645-1755 kuhncenter@gmail.com

Bosk CL. Forgive and Remember: Managing Medical Failure. 2nd ed. Chicago, IL: University of Chicago Press; 2003
Zilbert NR, Murnaghan L, Gallinger S, Regehr G, Moulton C. Taking a chance or playing it safe: reframing risk assessment within the surgeon’s comfort zone. Ann Surg. 2015; 262(2):253-259.

Kenneth A. Lipshy, MD, FACS

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