Assessing suitability for therapy Topic 1 Psychotherapy Supervision

Who should be considered?  Depression with reactive affect  Personality disorders  “I think something’s wrong with me, and I don’t know what”

Who should not be considered?  Unmotivated  Psychotic disorders  High risk situations  Remember that, if dynamic psychotherapy is successful, the patient usually becomes worse before they become better.  The process is painful (hence “psychosurgery”)

What is the therapy for?  Insight generation  “Someone to talk to”  Understanding oneself  Resolving X symptom  GOALS MUST BE SET IN PSYCHOTHERAPY

What predicts a good outcome to therapy  Psychological mindedness  At least one meaningful relationship  Lack of risk factors  Strong motivation  Circumscribed problem  Evidence of achievement

What prevents a person from being ready for therapy  Lack of Psychological Mindedness  Capacity for introspection  Risk factors:  Chronic addiction  Serious suicide attempts  Chronically incapacitating phobic or obsessional symptoms  Evidence of gross destructive or self-destructive 'acting out' behaviours.  Malan (1974)

Remember  You want to forge a therapeutic alliance  What is going to affect your emotional connection with the patient?  What is going to influence your ability to encourage mentalisation?

Process  Consider psychotherapy  Assessment phase  Treatment Contract

Assessment Phase  “We are going to trial four sessions of therapy. It will give you an opportunity to see what it will involve and what the process is. It will also give me information to determine whether this intervention is appropriate for you at this time.”  “Even if we do not end up going ahead with psychotherapy, this will still give us useful information that will help plan the rest of your care.”  “The process of psychotherapy is long and very difficult, and it is important to have this assessment phase to make an informed decision regarding the potential risks and benefits.”

What do you look for in Assessment  Can I cope with speaking to this guy for a whole year?  What is his problem?  What does he think is his problem?  How does he respond to interpretations?  What is his defensive profile?

The essential problem… Likelihood of needing psychotherapy Likelihood of failing psychotherapy

So, for a better outcome  How does my patient do in assessment?  What else have I learned about them?  What can I communicate back to them, and to the treating team?  Is it possible that the problem with the patient’s progress in the assessment is related to me? If so, would they do better with someone else?

Remember  There is no medical intervention more powerful, or more dangerous, than dynamic psychotherapy

Syllabus  What is Psychodynamic Psychotherapy  Attachment and Mentalisation  Assessing Suitability for Therapy  Techniques 1 The Frame, Boundaries and Free Association  Techniques 2 The Point of Maximum Pain  Techniques 4 Transference and Countertransference  Techniques 5 Resistance  Techniques 6 Interpretation and the Third Observer  Techniques 7 Defense Mechanisms  Techniques 8 Reformulation, Communication, Documentation, Termination  Models 1: Ego, Object relations, self, attachment  Models 2: Klein, Kohut & Kernberg: Narcissism, Object Relations and Self Psychology  Models 3: Conversational, Malan: Interpersonal  Formulation 1: The Six Core Psychological Problems  Formulation 2: Personality Disorders and Defensive Styles  Case Studies