Lisa is a 35-year-old lady, diagnosed with depression. She has been referred by her psychiatrist for psychodynamic psychotherapy. According to her therapist, Lisa has the ability to conceive of her own mental state as explanations of her behaviour. Nearing the end of her therapy session, Lisa blurts out ‘I am abusing my children’ before quickly shifting the topic to other things.
What is the most immediate appropriate thing for the therapist to do?
B. In the USA, therapists have a legal duty to warn and protect third parties endangered by their patients. In the UK, there is no binding requirement on clinicians to disclose dangerousness. The decision to disclose is based on the judgment that the responsibility to protect the public outweighs the duty to the patient to protect confidentiality. The clinician has the responsibility to make a considered decision whether or not to infringe the right to confidentiality. Statute law (e.g. notification of diseases) determines when the clinician ‘must’ infringe that right; case law when he ‘may’ do so. Most psychotherapy falls under the latter. Each case must be considered on its merits, possibly on the basis of a risk assessment, and where there is a doubt, the clinician must discuss it with another clinician. In any case, welfare of children is of foremost importance. In this particular case, Lisa said she was abusing her children. We do not know what she meant by ‘abuse’. So, as common sense would inform, the first step is for the therapist to confirm what she means by ‘abuse’. If there is a need, the next step would be an informed risk assessment. Confidentiality and disclosure are usually discussed with the patient before therapy. Since there is a potential risk to children, ending the session and reassuring Lisa about confidentiality are obviously wrong choices. Premature reporting to social services would result in unnecessary labeling and also possible loss of rapport and therapeutic alliance. Criticizing her would also lead to a break in the therapeutic relationship and would be against the principles of ‘unconditional positive regard’. If there is a case for disclosure, the patient herself should be encouraged to disclose to social services, as this would be in the best interests of the children involved and the patient. It is generally thought that inexperienced staff and students should not inquire about abuse or ask known victims about details of their experience, although they may be approached by patients making tentative attempts at disclosure, the general rule must be that inexperienced individuals should not invite discussion of a sensitive subject such as sexual abuse unless they are being supervised and trained to deal with it. In this case, it is thought that the psychotherapist is being supervised and would do a general risk assessment based on history and mental state.
References:
Which of the following represents the concept of borderline personality organization?
E. Otto Kernberg proposed the term ‘borderline personality organization’ (BPO), a broad concept encompassing all severe personality disorders. BPO is a stable permanent state based on four criteria: diffuse identity; primitive defenses, including splitting, projection, and projective identification; intact reality testing that is prone to alterations and failures because of aggression; and object relations characterized by splitting. The term ‘Identity diffusion’ was developed by Erikson and later used by Kernberg in his concept of BPO. In psychodynamic terms an individual with identity diffusion has not integrated good self-images with bad, and, instead, has multiple, contradictory self-images, some good, some bad. These are invoked at different times and in different situations so that a meaningful, integrated image of the self is never formed. Salman Akhtar delineates the syndrome of identity diffusion as consisting of six clinical features:
This syndrome implies severe personality pathology. The inner world in BPO according to Kernberg, is characterized by split objects. Instead of stable and smoothly integrated internal representations of people and their relationships, the self and others are experienced in contrasts of either black or white – ‘no grey zones’. These people generally have an intact reality testing, but are prone to breaks in it, leading to the so-called ‘micropsychotic’ episodes.
In dynamic psychotherapy, the therapist at times uses certain techniques that represent the ‘supportive’ end of the psychodynamic continuum rather than the ‘expressive’ end.
Which of the following is suggestive of a ‘supportive’ technique?
E. Dynamic (psychoanalytic) psychotherapy is often conceptualized as being on a continuum of expressive to supportive. Traditionally, psychoanalytic psychotherapy has focused on the recovery of repressed psychological material. This process has been called ‘expressive’ and is distinguished from the ‘supportive’ psychotherapies, which concentrate on supporting healthy defense (coping) mechanisms. The therapist may employ more or less expressive and supportive interventions, depending on the needs of the patient. Among the given responses in the question, advice giving leans towards the supportive end of the continuum. In addition to advice giving, other techniques usually employed that are at the supportive end of the continuum are praise, suggestions, reassurance, environmental intervention, and manipulation.
The process by which unconscious ideas are repressed and prevented from reaching awareness because they are unacceptable in psychotherapy is called:
C. Resistance is broadly defined as the conscious or, more often, unconscious force within the patient opposing the emergence of unconscious material. Resistance is thought of as the patient’s attempt to protect her or himself by avoiding the anticipated emotional discomfort that accompanies the emergence of conflictual, dangerous, or painful experiences, feelings, thoughts, memories, needs, and desires. Resistance occurs through the use of unconscious defense mechanisms. The recognition, clarification, and interpretation of resistance constitute important activities of the psychoanalyst and the psychoanalytic psychotherapist, both of whom must first appreciate how a patient is warding off anxiety before understanding why he or she is so compelled.
Reference:
Jack is a 35-year-old man who perceived his parents as overly authoritarian. His therapist on the other hand, is friendly and non-authoritarian, but at times fi rm and sets definite limits. The attitude of his therapist gave Jack the opportunity to identify with a new parent figure. This is an example of a process described by Franz Alexander.
Which of the following terms best represents this process?
C. The therapeutic relationship between therapist and patient gives a therapist an opportunity to display behaviour different from the destructive or unproductive behaviour of a patient’s parent. At times, such experiences seem to neutralize or reverse some effects of the parents’ mistakes. If the patient had overly authoritarian parents, the therapist’s friendly, flexible, non-judgemental, non-authoritarian, but at times fi rm and limit-setting attitude gives the patient an opportunity to adjust to, be led by, and identify with a new parent figure. Franz Alexander described this process as a corrective emotional experience. It draws on elements of both psychoanalysis and psychoanalytic psychotherapy.
Click to expand