(Caveat: Prior permission was sought to write up the client's case for teaching purposes, and no identifying info was released. So, please do not reproduce this in any way, without prior consent of the author, me)
Paper written in December 2013; Psychodynamic Case of Frieda (fictitious name). Features case history, conceptualisation, diagnostics, treatment, technique, and discussion questions.
Reason for referral:
Frieda was initially referred by her psychiatrist for treatment in relation to her depressive symptomatology. She was first seen as an adult client in 2012 and was previously seen by a female psychologist. Subsequently, Frieda was transferred to myself after having seen her for a session. It was highlighted that the client requested for a change in therapist, specifically for a male psychologist.
The context surrounding the transfer was that the client met with her previous therapist for an initial assessment interview, which led to significant concerns that Frieda was not sharing much about her problems. In addition, Frieda was reported to have appeared withdrawn and spoke about wanting to harm herself.
Presenting Issues:
Some of Frieda’s difficulties included: issues related to declining performance in her studies, problems relating with others (family and schoolmates), tendencies toward self-harm (cutting), suicidal ideation.
Saying very little in the initial interaction, she gave distressing and vague descriptions about herself and her situation – “Very bad, everything is very bad”. She described that she was afraid of social interaction, constantly feeling like she could not connect with and interact with people. She spoke frankly about how terrifying it was for her to speak with others when she perceived others in general “bitching” around about other people. Of note, this experience was reportedly heightened with women.
Background:
Developmental and Familial History
The client, Frieda, is a 19-year-old girl who presents with a history of reported molestation by her father and exists within a traditional Chinese family. The eldest of three children, Frieda recalled vividly in Secondary Three when she awoke to her father in her bedroom early one morning. She disclosed that her father touched her inappropriately and she could do nothing but remain still under the covers until the ordeal ended. Reportedly terrified and feared the backlash of telling tales, Frieda did not dare to divulge this to anyone. Finding sufficient courage to speak with her paternal grandmother and hoping for some help, she shared that her grandmother blamed her for the blatant accusations. Following which, Frieda’s attempts to gain assistance with her own mother was met with warning and disappointment. She revealed that her mother was indifferent towards any possibility that her father was unfaithful. At the time of the referral, Frieda stated that their father had disowned both her and her sister.
Her family system was described by Frieda as critical and invalidating, and tended to protect the “perpetrator” who is viewed as “a good father”, and someone who makes a living as a respectable figure in the public eye. Her father was illustrated as a strict and authoritative figure that used to “beat me up if I scored less than 90 marks for exams”. She gave details about the harsh form of punishment she received by indicating that one mark less from full marks deserved 10 strokes of the cane. Furthermore, Frieda’s father was reported to have been involved with another woman since she was about five years old, and he would take her along to meet this woman. Despite his philandering ways, Frieda was warned that she would be harshly punished if she ever told anyone. According to her, her father continued to cheat on her mother, but only became overt in his extramarital affairs from early 2011. To Frieda, she explained that everyone at home knew about his affairs but continued to deny the reality of these happenings.
Her mother, on the other hand, was depicted as a mother who neglected her child’s presence. She recalled being told by her mother in primary school “you’re not my daughter, just your step-mother”. Clarified as her birth mother, Frieda reported rejection from an early age and “blamed for just about everything”. According to Frieda, she remembered having to apologise all the time, and was never close to her own mother. In a response to Frieda’s pleas for assistance and support, Frieda was warned that her father was the breadwinner of the family, and her mother reportedly said that she would deny anything even if her husband raped both her daughters.
Frieda’s relationships with her younger brother and sister were reportedly distant and described as “unclose”. Being “on bad terms” with her sister, they had frequent quarrels and difficulties with each other until recently when they were both disowned that their relationship had somewhat improved. It was then that her sister revealed to Frieda that her father violated her as well. Regarding the relationship with her brother, Frieda spoke of him as the first person she ever trusted but began to grow apart about a month after his father’s affair became obvious to the family.
Reportedly the only close friend she had, Frieda spoke sadly about being abandoned by her to live in Canada with her family. She complained that “no one ever listens”, including this friend of hers. Frieda shared that she constantly felt patronised by her when she confided about her on-going struggles.
Academic History
Discussions regarding her schooling revealed that she had significant interpersonal difficulties throughout primary and secondary school with both classmates and teachers. Frieda recalled her classmates “laughing and teasing” about her parents when she tried sharing with them the things that happened at home. Speaking about her secondary school days as the “horrible memories”, she gave details of not being able to participate in physical education classes due to a certain blood disorder, leading to her exclusion in activities with her classmates.
While unsubstantiated and lacking in detail, Frieda shared about a relief teacher who had text messaged her on her mobile phone with words like “goodnight”, which she found strange coming from a teacher. Upon sharing this with her classmates, she was reportedly “outcast” by her peers and cited a reason that he was a popular teacher and others were unhappy that he displayed this care for her.
Despite these issues with peers and some evidence of inappropriateness with a teacher, Frieda described herself as a hardworking student who prided herself in her academic abilities and spent time by herself studying and “doing better”. Similar to high expectations expected of her by her family of origin, she expected much from herself when it came to performance in scholastic activities. Reporting above average grades, she tended to score well in examinations.
Following her promotion to a respectable junior college at about 17 years old, Frieda continued feeling insecure at the time and attempted sharing her discomfort with her father. Although she described the experience as the very first time she felt she could trust her father, that feeling was short-lived. Her father responded by taking her to a GP, resulting in her initial referral to child psychiatry.
Shortly after, Frieda reportedly transferred to a different junior college where she quickly experienced similar feelings and struggles. She recalled breaking down two days into her new school and thought to herself that she did not want to disappoint her family. Feeling conflicted by frequent “cover ups” allegedly orchestrated by her family, Frieda was faced with being told not to “think too much” about her problems.
Frieda subsequently pursued a tertiary education at a local institute, and took up psychology units as part of her course of study. She continued to report interpersonal difficulties and perceived others as disliking her, especially when group work was required. She reported being most comfortable on her own, explaining that this also prevented others from taking advantage of her hard work and found it difficult to assert her displeasure with others whilst maintaining superficial relations with them.
Medical and Brief Psychiatric History
Apart from her reportedly diagnosed blood disorder, she is fairly healthy and did not have any significant health complications. According to her records, she was previously seen as a child client at a prominent psychiatric clinic.
While she had been seen by a psychologist at the time to address her emotional difficulties in the context of her issues at school, Frieda reported that she had felt betrayed by her psychologist on several occasions but chose not to elaborate. Treatment at the time took the form of Cognitive Behavioural Therapy, and was intended to be middle-term work, but she felt that it remotely addressed her issues. Revealing that she has massive trust issues with women, Frieda reported that she had felt the same disturbing feelings upon seeing her psychologist prior to our own sessions. She added that she experienced lots of distress and was disappointed that the psychologist dealt with her by issuing a “suicide contract” instead of working with her to understand the reasons why she felt suicidal. She added that she could not trust the female psychologist, and requested for a male instead.
During our initial appointment, Frieda made a point to communicate that she had been feeling upset and cut herself the week before. In addition, she reiterated at several points in the session that “you won’t believe me because I’m ugly, but I was molested”.
Assessment:
Mental Status Examination
Frieda presented as a young, Chinese woman, of medium build, usually dressed in casual attire. She typically wears clothes that covered her whole body and puts on a jacket in session. She wore her hair long and did not appear to be made up. She would bring along a haversack and carried books in hand, and appeared to be doing some form of reading prior to our sessions. During our sessions, she was observed to clutch onto her haversack and remain fairly rigid in her chair. While she gave good eye contact, there were times when she just remained quiet and appeared apprehensive about what to say next. There were times when some evidence of bruising, scratches and cuts were observed on her forearms when she rolled back her sleeves.
Although she can be emotionally reactive at times, Frieda was observed to actively dissociate when conversations covered issues that led to some indication of an experience of difficult emotions. When queried about what happened to her in such instances, she would apologise profusely and report that she did not hear a word I said. This is usually accompanied by long silences and occasional bouts of tearfulness. Nevertheless, she is able to converse in a clear, relevant manner, and displayed curiosity about my intentions surrounding questions or statements made in session. Although she appeared to respond well to empathic statements, she struggles with hearing reflections about her tendency to minimise her own strengths and abilities.
Diagnosis:
· Dysthymia with Borderline Personality Pathology
Differential Diagnoses:
· Recurrent Depressive Episode, current episode moderate, without psychotic symptoms
· Post Traumatic Stress Disorder
· Social Anxiety
· Reactive Attachment Disorder of Childhood
Formulation:
Predisposing
· Emotionally invalidating childhood environment
· Disorganised attachment arising from disparate parenting styles
o Father: Cold/authoritative/critical/dismissing
o Mother: Rejecting/non-protective/controlling/verbally abusive
· Real/imagined sexual transgressions by her own father
· Unsupportive familial environment – culture of privileging men in the family
· Evidence of social exclusion in school
Precipitating
· Onset of difficulties was gradual with a clear precipitant in late 2012
o A deterioration in the relationship with her father led to Frieda’s experience of considerable distress when he made his decision to disown Frieda.
Perpetuating
· Tendency toward dissociation and emotional suppression
· Tendency to oscillate between feeling sorry and annoyed with others
· Tendency toward approval seeking
· Self-loathing and heightened sensitivity – Feelings of “badness” about herself
· Coping with her emotional pain by cutting herself
· Self-esteem hangs on her ability to perform well at academia
· Frieda’s high expectations and unrelenting standards of herself
Protective
· Her young age
· Her above average intelligence
· Her curiosity in session
· Keenness to address her difficulties
· Her capacity to stay enrolled in tertiary education
· Capacity to feel safe in the confines of her therapy sessions
· Some evidence of accepting and reflecting on trial interpretations of her difficulties
Prognosis
· Initially assessed to be poor, but latest appointments showed an emergence of some awareness and insight, though limited.
Treatment
Goals
The broad therapeutic goal worked out with the client was to make sense of her current experiences in light of her past experiences, and to assist in the alleviation of her depressive symptoms. Specifically, these would take the form of “working through” her difficulties by keeping her feeling emotionally and physically safe in our sessions, as well as working on her emotional regulatory capacities.
Course of Treatment
Treatment involved a psychodynamic approach, focused on attachment-related aspects of her own development through her life. In contrast to long-term psychodynamic psychotherapy, short-term to middle-term work is intended in Frieda’s case, to assist with building her capacities to deal with and tolerate her own emotional distress. Particular aspects assessed to be of major concern are her tendencies toward dissociation and her personal safety, as well as on-going perpetration of the reported molestation.
Building rapport and client felt security at initial assessment appointments is of utmost importance as an initial goal, where the “therapeutic frame” is set (Gray, 1994). These would include limits of confidentiality, expectations of the therapy, and the roles of the therapist and client during the course of therapy. Strict boundaries are required to be set and were achieved by keeping sessions to the hour, a prerequisite that is crucial especially in Frieda’s case. This maintains boundaries but also assists with a predictable context to promote the experience of safety. Once the frame is set, adhering to the structure consistently would add to helping her feel safe. Any deviation from this would suggest differing patterns of relating in the session, on the part of either the client or therapist. Depending on what aspects may be observed or discussed in sessions, interpersonal aspects of the client-therapist interaction can be highlighted as points of discussion.
On-going exploration and links to her childhood experiences would be highlighted to enrich Frieda’s understanding of her patterns of relating across her relationships and expectations of self and others (Moss, Bureau, St-Laurent, & Tarabulsy, 2011). A large focus in the work with her includes working in the transference, whereby discussions are targeted at her expectations of how she would anticipate and respond to interactions with men and women in her life. These included individuals like her parents, family members, schoolmates and experience of her own therapist. By reframing the focus of how her own upbringing inadvertently led to being constantly let-down by her own parents, her anger and frustration toward them is encouraged to be expressed more openly. Psychodynamically speaking, anger that is kept within tends to be toxic, and thus requires emotional awareness and regulation (Holmes, 2010). Conversations surrounding how and why anger is better expelled, were used as a form of scaffolding for her to make sense of her dissociation. Her dissociative experiences were framed as how her mind deals with strong emotional difficulties in highly unsafe situations such as her family environment. When more appropriately expressed, her anger can take the form of honest and assertive speech, as opposed to being upset with herself and feeling inauthentic.
Another concurrent goal for Frieda’s treatment included “anchoring” and approaching her experience of highly distressing emotions in our sessions with care. The objective is to provide her with a positive emotional experience of not being dismissed or rejected, as opposed to encouraging her to set her fears and anger aside when she felt them strongly. Here the recognition of the existence of Frieda’s “defence mechanisms” (Freud, 1936; Valliant, 1993) is crucial for our understanding of her emotional experience and disorganised pattern of responses. In line with classical psychoanalysis, Frieda’s defences are both necessary – so that it is useful for her to be unaware of the potentially disruptive erotic and aggressive feelings, as well as an encumbrance with removing these thoughts from awareness. This is where Frieda struggles between being overwhelmed with emotion in ambivalent attachment and the extreme “switched-offness” of the avoidant position (i.e., where she dissociates).
Despite its self-protective dynamic, the effort of removing such thoughts from conscious awareness restricts and compromises loving, and self-assertive possibilities (Holmes, 2010). From an attachment perspective, it is argued that understanding affect of our own and that of others is essential for negotiating interpersonal life. Therefore, a different view may be helpful to assist her making sense of her emotional experience with her, regardless of how dramatic or closed-off she might be in sessions. Contrary to traditional CBT techniques used to distract or refocus, the client is encouraged as a goal in sessions, to express her emotions if she wanted to, and to maintain a reflective stance if she could. The ultimate goal of this is to teach her more adaptive ways of reacting to her own experience of emotions, and to build her reflective functioning capacities. According to Fonagy, Gergely, Jurist, and Target (2002), the capacity to reflect on one’s story is a feature of secure attachment and has been shown to be a protective factor leading to secure attachment, regardless of how traumatic a childhood may have been.
To date, Frieda had attended about 25 sessions over the course of 11 months. Although there were occasions when she had decided not to turn up for various reasons discussed in varied detail as part of her presenting difficulties, she continued to attend the sessions regularly. She is an on-going case who had displayed vast improvements in her presentation, notably in the decrease in her tendencies to dissociate in session and self-harm. Currently, she had reported that she no longer copes in these ways. She is more willing to discuss difficult situations that arise from interpersonal relationships instead of just writing them down on paper, and displayed a broader range of affect in sessions apart from anger, to disappointment and fear. She had in a number of instances attempted at making jokes, and smiling appropriately in response to quips about her own life. In particular, she currently displays an emergent awareness of her tendencies to keep her emotions at bay by a reluctance to experience the pain of being hurt repeatedly. Interestingly, she shared in one of her latest sessions that she was in a romantic relationship with a male around her age.
Nevertheless, there are a number of outstanding issues that require addressing in the course of Frieda’s treatment. She remained reluctant to interact more with others at school as she viewed that “human beings are dangerous” and that she feared being singled out as the problematic person in a group. As a result, she continued to avoid these circumstances and felt safest by herself with her books. Her self-worth and self-esteem still hinged on her ability to perform well at school, as well as flippant views toward her family – “sometimes they are right, but sometimes I think they don’t understand”.
Plans for further work with Frieda included discussing her protectiveness toward her own family and how that impacts on how much she values their opinions as opposed to her own. This is a dynamic that existed between (and paralleled) our therapeutic relationship as well. Given that Frieda constantly brings in recurrent, vivid dreams of being oppressed by her family and violated by her father, attempts can be made to interpret some of these dreams along with her emotional experience and life history. The goal was to build her understanding of her own fears and desires, whilst making meaning and identifying possible parallels of her patterns of coping with distress.
Discussion
i. The Parallel Process – “The Me in You” and links to the client-therapist process
During the initial phases of seeing Frieda for regular weekly sessions of psychotherapy, it had occurred to me that I had regularly entered our appointments with a heavy heart. It was around the commencement of our sessions that I had to deal with my own loss of a treasured friend, and carried emotions of self-blame into my sessions. Having analysed its significance with my own therapist, I realised that I was walking into the consulting room carrying issues and concerns that reflected my own. This provided a crucible for self-reflection that has both benefitted my work with Frieda and propelled my own understanding of how she can affect others around her.
Frieda consistently enters into our sessions with heaviness analogous to mine that embodies pain and disappointment of others and herself, which according to her, caused the breakdown of her own family ties. Not long into our appointments, I noticed that my own thoughts while sitting with her had tended to go “elsewhere”. I recognised my own upsetness and pain, but wondered why my mind kept drifting off that way as opposed to being there focused on her. My sessions with her tended to be scheduled in the mornings and there were no particular reasons strong enough to explain my lack of concentration, especially when I have no similar experiences with other clients on my caseload at the time. Having established clear therapeutic boundaries within the frame early on, departure from this frame signified something happening outside the boundaries of our interaction. In her case, Frieda brought into the consulting room her own transference reactions, whilst I had a narrow1 counter-transference experience of my own.
As a therapist, one could do two things: to allow our own issues to get the best of us, and get drawn into feeling “dissociated” from one’s own feelings with the client, or to use our own process to benefit the client, and the client’s process to propel our own. The worst-case scenario here is that both therapist and client are actively dissociating in the appointment, which make for an interesting but disturbing dynamic for the undiscerning therapist. My own recognition of this subtle, but important dynamic assisted me to consider what was at play in the room. Recalling her distal factors and history of developmental trauma, I began to differentiate what was my own experience and what I had noticed in Frieda. In essence, this gave way to recognising where my mind would go and how that experience may parallel Frieda’s own unconscious removal of her own emotional pain. By kick-starting my own mentalising/self-reflective process, I was able to highlight and unpack with her the typical events that occurred when she gets into a bout of self-blame (Bateman, Brown, & Pedder, 2010). This facilitated Frieda’s own process of thinking about her experience, instead of reacting instinctively to those familiar self-denigrating feelings. It was by pointing it out to her in the moment that we managed to keep the conversation centred on the present, instead of splitting-off2 and projecting her painfully experienced feelings away from conscious awareness.
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1. Narrow counter-transference refers to issues relating to the therapist’s own self as opposed to broad counter-transference, where the therapist projectively identifies with an aspect of the client’s emotional experience that is not itself owned by the therapist. Refer to (Bateman, et al., 2010) for more complete definitions of transference and counter-transference.
2. Splitting is an important developmental achievement of the paranoid-schizoid position (Klein’s early stage of development) and allows the ego to emerge out of chaos and to order its experiences (Segal, 2008). The ordering of experience which occurs with the process of splitting into a good and bad object, however excessive and extreme it may be to begin with, nevertheless orders the universe of the child’s emotional and sensory impressions and is a precondition to later integration. For Frieda, splitting is also the basis for her defensive repression. Given that early splitting for her has been excessive and rigid, later repression is likely to be an excessive neurotic rigidity (Segal, 2008). When early splitting is less severe, repression will be less crippling, and the unconscious will remain in better communication with the conscious mind. What is referred to, as splitting-off is a primitive mechanism of removing what is experienced as too frightful or too difficult to manage at a conscious level. Instead, it becomes easier to set it aside and as has been observed, dissociated from the emotional experience.
Interestingly, in my own clinical supervision where discussions of the existence of this parallel process and how this similar dynamic was played out between my supervisor and myself made immense difference for my work with Frieda. In therapist training, often underemphasised in theoretical conceptualisations and empirical studies is the concept of parallel process (comments below) in clinical supervision (McNeill & Worthen, 1989). Argued to be the focus for some of the most potent and impactful interventions within the supervisory relationship, the supervisor and supervisee uses what is occurring in both the therapist-client and therapist-supervisor relationship to enable the therapist to use their own experience of emotional difficulties in session to facilitate understanding of the client’s situation (McNeill & Worthen, 1989). As my supervisor and myself ascertained certain aspects of the relationship between Frieda and myself, we examined similar aspects of the supervisory relationship that may manifest itself in a reciprocal manner in the therapeutic setting. Noticing the pattern of discussion in one session of supervision, we drew a focus upon the metaphor of “growing a voice” and asserting oneself in supervision. I found that this experience of mine in supervision, highly resonated with Frieda’s struggle with growing her own voice in expressing her emotional pain, while anticipating the disappointment that usually followed. Thus, in increasing my own emotional awareness of Frieda’s own struggle, I gave more space for her to come forth with what, and how much she wanted to say. I encouraged myself to sit with the distress of being with a client who talked little, and to contain my frustration with her even if her utterances were anticlimactic. This experience helped me gain a more complex understanding and appreciation of her transference reactions to disapproving/abusive males.
ii. Dream Interpretation – Frieda’s dreams of being violated by a man whom she could not identify
Dreams are a powerful way of accessing an individual’s unconscious, particularly when a process of therapy has commenced. The discussion of disturbing material in our appointments with clients can activate and evoke strong feelings, which might require making sense of with the client at the right time. Drawing caution to haphazard interpretation, it is important to consider Frieda’s sensitivity as a victim of trauma. For that reason, it is always wise to keep the client’s history in mind, an awareness of their anxieties and defences, and clarify how they feel during and after the dream (Segal, 2008). While talking about these dreams can be frightening for the client, this was only possible on the basis of a robust therapeutic alliance.
Frieda shared a recurring dream that occurred somewhere around the eighth session which involved her being raped by a man who did not have a face. This same dream occurred fairly regularly after our appointments together, and Frieda would point that out in our sessions. Reports of her dream were usually accompanied by feelings of fear and the scene might quickly change, and she would find herself appearing in a school bus, being pressed for her lunch money by a classmate. Following which, she was asked by her paternal grandmother to give up her money to the classmate without hearing what Frieda had to say. According to Frieda, she reluctantly gave up her money and felt disappointed thereafter.
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1. Refer to McNeill and Worthen (1989) for a more comprehensive explanation of the concept of parallel process in psychotherapy supervision.
While this “faceless man” might literally be her father, another interpretation of the symbol formation might be that this is a transference reaction toward her therapist who sought to “undress” her with his questioning. On the one hand, I had forced myself upon her, while on the other; I might have displayed attributes that Frieda perceives as appealing enough to work hard to seek approval from. During appointments, she would tend to acquiesce to statements made, and she would apologise profusely for accidentally interrupting me or being slightly late for a session. Her own reactions to her own abusive father would then be played out in our therapeutic sphere. Once this display was linked with aspects of her dream, and interpreted, Frieda was able to show some capacity to digest what I had presented to her. Of course, she may just accept these interpretations as lore, but Frieda responded well to the interpretation about her parents in the past, and what occurred between us in the session. She sighed and looked relieved, which was followed by displays of heightened curiosity by asking to know more about our discussion.
Lo and behold, at our latest appointment, Frieda shared that she had a chance conversation with her estranged sister, who spoke about their father’s violent attempts at punishing both sisters one day in their primary school days by locking them out of the family home. Recalling multiple quarrels between their parents at the time, her sister described witnessing their father put his hands around Frieda and tried to force her off the parapet from the corridor. According to Frieda, she recalled having dreams of being strangled by her father recently, those of which she was previously condemned for making such “outrageous” accusations when confiding in her family. Frieda realised in this session that while everyone was unsupportive, her sister finally came forward with information that corroborated with her own experiences. This realisation and emotional validation from her sister helped Frieda make sense of her own abilities to recall events and place some trust in her own recollection and experiencing.
iii. Frieda’s admission of her fondness of her therapist and managing that in session
Having experienced some positive instances with me despite her emotional ups and downs, and trying to understand it, much time was spent helping Frieda feel safe and comfortable in the therapy. This included education, explanation about the therapy, and attention to particular moments of apprehension and mistrust. Frieda seemed to alternate between trusting, positive feelings and sudden anger/frustration, suspiciousness, and withdrawal. She became more and more aware that these reactions reflected her old feelings (“the old stuff”), which alternated between childlike trust and then betrayal and fear.
Finally, around our 23rd session together, Frieda decided to slip in that she “might be idolising” me given that her reported experience with me had been intimate and she reported looking forward to our sessions together. Exploring the reasons why, Frieda explained that I was able to tell what she was thinking and feeling without her needing to say much. This was something she described as natural and she did not need to explain herself too much, while not feeling pressured at the same time. Taking Frieda’s comment and her changes observed in therapy into consideration, we look to the Theory of Object Relations to make sense of these.
With splitting, are connected persecutory anxiety and idealisation (Segal, 2008). For Frieda, some degree of persecutory anxiety is a precondition for being able to recognise, appreciate and react to actual situations of danger in external conditions. On the other hand, idealisation is the basis of the belief in the good objects and of oneself, and is a precursor of good object-relationships. According to Segal (2008), the relationship to a good object usually contains some degree of idealisation, and this idealisation persists in many situations such as falling in love, appreciating beauty, and forming social ideals – emotions which, though they may not be strictly rational, add to the richness and variety of our lives.
Sensing her honest but overt neediness in particular moments, it was interpreted to her that perhaps there were aspects of our relationship that she desired in her own relationship with her father, where safety and understanding were non-existent. This provoked discussion where she would have quickly went to silence or decide not to attend in the initial phases of therapy. It became easier now to stay in the moment with her and at anticipating when her shifts would occur, while interpreting and clarifying them more clearly. Currently, we have developed a kind of rhythm – that of discussing her new relationship, her periodic interactions with her parents/family, and feelings and thoughts about me. As she moved from one aspect to the other, Frieda appeared to be able to apply some of her understanding of her old relationship templates that played out in each situation. Looking stronger and more confident compared to her initial presentation, Frieda also seemed looser, more playful, and wittier than before.
Discussion Questions
· Compare the similarities and differences between how a therapist practicing CBT might approach Frieda as a client, as opposed to a psychodynamic psychotherapist. What do you think are the potential strengths and pitfalls?
· Imagine yourself in Frieda’s shoes and setting aside the evidence-based practice argument for a second. What would you consider to be important elements of your own treatment assuming you have severe personality issues and deficient coping strategies?
· It is interesting that theories of development (e.g., Bowlby’s Attachment Theory, Freud’s Psychosexual Theory of Development, Klein/Bion Theory of Object Relations) were briefly introduced in some undergraduate programs but lacked focus in postgraduate training. As far as Frieda’s treatment goes, is psychotherapy meant to manage her behaviours or to heal her of her underlying difficulties?
· Is the primary goal of psychotherapy meant to make you feel better, or is that a by-product of something else? How would this potentially impact Frieda’s treatment if it were based on her request of symptom alleviation?
Additional information
· Given that Frieda liked to draw and write in our sessions, she was encouraged to express herself as part of projective assessment. Below is a picture she drew to describe her relationships and how they viewed her. This is symbolic of her formed object relations, whereby she is the embodiment of the bad object and others (even her internal self) are separated from her. Her statement, made into a question, raises interesting notions of transference enactments in our sessions together, and similar apprehension she has of me, as with others.
· Assessment profiles – at the 2nd session, the Dissociative Experiences Scale (DES-II) was given as a measure of her tendency to dissociate. She scored in the upper limits and results suggested that Frieda was in the moderate to severe range. Given that clients tend to rate highly on this self-report scale, the presentation at appointments were taken into consideration.
· For therapists – More on the Therapeutic Frame and its application
According to the University College London’s website (http://www.uck.ac.uk/clinical-psychology/), the therapist’s ability to establish and manage therapeutic frame and boundaries is a core competency.
What it the therapeutic frame?
An ability to draw on knowledge that the therapist’s boundaries and those of the therapeutic frame will have an idiosyncratic meaning for the client, and that this will inform how the client experiences the frame and any changes to it.
It is being able to draw on knowledge that the physical setting of the therapy room is invested with an affective charge that is linked to the relationship with the therapist.
Knowledge that planned and unplanned interruptions in the treatment may impact on the client and that this requires acknowledgement and understanding when it occurs. This includes knowledge of the dynamics of separation, loss and mourning as the basis for understanding the client’s subjective experience of breaks during the treatment.
How to apply these to seeing clients?
An ability to establish clear parameters within which the treatment will take place (i.e., setting; frequency and length of sessions; use of the therapeutic space where applicable; limits of confidentiality; expectations of the client [e.g., that they will say what comes to mind/bring in their dreams etc.]; arrangements over breaks in therapy)
To maintain consistency in relation to the agreed parameters and therapeutic stance so as to create a stable and secure setting for the client through:
- Maintaining the therapist’s analytic attitude
- Being alert to the meaning to the client of any changes to the agreed setting, whether planned or unplanned
- Helping the client to explore their experience of any changes
- Attending to and interpreting the therapist’s understanding of the client’s experience of separations/discontinuities in the treatment in the frame
To be receptive to the client’s conscious and unconscious experience of the setting and its boundaries, and to help the client to articulate this experience so as to:
- Ensure that the client’s agreement to the therapy and its boundaries is rooted in an exploration of their conscious and unconscious feelings and fantasies about the therapy
- Identify early transference patterns that will form the basis for eventual interpretations
To manage deviations from the established frame
- To evaluate the meaning of the client’s requests for modifications to the parameters of the therapy as the basis for responding to such requests
- To help the client explore unverbalised feelings and unconscious conflicts to counter the pressure to act out and so protect the viability of the therapy
- To maintain (or regain) a reflective stance when managaing forms of acting out in relation to the setting (by the client, therapist or both)
- To set clear limits where necessary (e.g., if the client’s behaviour undermines the viability of the treatment)
To manage interruptions in the treatment
- To prepare the client for planned interruptions (e.g., holiday breaks) in the treatment by helping them explore their conscious and unconscious responses to breaks
- To assess risk during breaks in the treatment and make arrangements for additional support when required
Refer to Gray (1994) for a more comprehensive reference to the therapeutic frame.
Fact Box 1:
Contrary to popular notion that Psychodynamic Psychotherapy is not evidence-based, many recently published works argue that it is both theoretically and empirically sound (e.g., Shedler, 2010; Summers & Barber, 2010).
Fact Box 2:
While psychodynamic therapy remains a popular and widely practiced form of treatment, its rich complexity, coupled with confusing terminology often leaves interested therapists in the rut. It is not an easy form of therapy to learn and master, but requires personal development in the therapist who is open to viewing issues in more complex ways.
Fact Box 3:
It’s not always about Freud and the penis! Psychoanalytic and psychodynamic writing over the decades has evolved and many forms of theory and technique had been worked through and furthered by others (e.g., Brief Psychodynamic Psychotherapy [BPP]; Core Conflictual Relationship Theme [CCRT] method; written works of Melanie Klein, Wilfred Bion, Hanna Segal), who made reading less effortful.
References
Bateman, A., Brown, D., & Pedder, J. (2010). Introduction to Psychotherapy: An outline of psychodynamic principles and practice (4th ed.). New York: Routledge.
Fonagy, P., Gergely, G., Jurist, E. L., & Target, M. (2002). Affect regulation, mentalisation, and the development of the self. New York: Other Press.
Freud, A. (1936). The Ego and the Mechanisms of Defence. London: Hogarth: Hogarth Press.
Gray, A. (1994). An Introduction to the Therapeutic Frame. London: Routledge.
Holmes, J. (2010). The Search for the Secure Base: Attachment Theory and Psychotherapy. Great Britain: Routledge.
McNeill, B. W., & Worthen, V. (1989). The Parallel Process in Psychotherapy Supervision. Professional Psychology: Research and Practice, 20(5), 329-333.
Moss, E., Bureau, J.-F., St-Laurent, D., & Tarabulsy, G. M. (2011). Understanding disorganised attachment at preschool and school age: Examining divergent pathways of disorganised and controlling children. In J. Solomon & C. George (Eds.), Disorganised Attachment and Caregiving (pp. 52-79). New York: Guilford Press.
Segal, H. (2008). Introduction to the Work of Melanie Klein. London: Karnac Books.
Shedler, J. (2010). The Efficacy of Psychodynamic Psychotherapy. American Psychologist, 65(2), 98-109.
Summers, R. E., & Barber, J. P. (2010). Psychodynamic Therapy: A guide to evidence-based practice. New York: The Guilford Press.
Valliant, G. (1993). The Wisdom of the Ego. Cambridge, MA: Harvard University Press.
In this article, we briefly explore why certain questions can be uncomfortable and ways to handle such situations with empathy. It is important for one to be aware of how impact of their words and for others to not assume the worst of intentions. Let us all take a moment, to foster a supportive and inclusive environment during this time.