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Reduction of stimuli |
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Removal from noxious environmental influences Negative stimuli |
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Environmental chaos D&A abuse |
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High EE interactions |
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Lack of positive stimuli |
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Homelessness/ isolation /living with self-absorbed others |
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Network of therapeutic relationships |
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Therapeutic responses from clinical staff |
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Positive stimuli |
Principles generated from healthier patients can be misapplied to more severely ill patients. Intensive treatment mindlessly applied can lead to adverse outcomes. Not all models comfortably fit all the varieties of behaviour observed clinically in inpatient settings.
Psychotherapy literature has not addressed the role that psychodynamics can play with the short-term inpatient admission. Most focuses on outpatients. Most that do consider its role deal primarily with long-term inpatients.
Is the meaning of events in the patient's life relevant?
Dynamic psychotherapy believes so.
Can we blend medication (pharmacotherapy or psychopharmacotherapy) + appropriate psychotherapeutic models to preserve the best features of both?
This has been called dynamic pharmacotherapy (Gabbard)
Behavioural model most suitable for the most severely disturbed disorganised individuals for whom verbal interventions have limited meaning, requiring coordinated unified consistent responses.
Object-relations model is suitable for understanding inpatients
Patients who don't have an integrated coherent sense of self experience themselves in a fragmentary fashion (fragments = part-self representations).
Fragments are experienced as complete representations of themselves for moments of time. Assessed at a moment in time, patients are likely to describe only one perspective of themselves, as if the other states (fragments) do not exist.
These fragments are linked to specific representations of people they interact with (part-object representations) based on their internal schemas
Object relations (OR) = the patient's blueprint or model for relating to people based on their previous interpersonal experiences
The patient's affect links the self & object representations:
part-self representation----Affect----part-object representation
Using the OR model, the therapist usually identifies the split off representation (part-self representation) rather than the affect (as occurs in classical dynamic therapy, which-aims to provide an understanding of behaviours by bringing into the conscious what is unconscious.)
OR model: the task is to clarify split off aspects of the patient's self and interpret the defensive purpose of such as split.
Attempt to gain active mastery of passively experienced traumas
Reactivating problematic relationships permit patients to gain control & be in charge.
Maintenance of attachments
Keep past relationships alive.
Avoid separation anxiety/ sense of abandonment.
Dysfunctional relationships are better than no relationship at all.
A means of communication
"I cannot articulate my internal experience but by creating similar feelings in you, you can empathise & help". Hurt treater.
Pathway for psychological change
Treater can provide new & different interpersonal relatedness that facilitates the internalisation of less pathological object relatedness.
Internalisation: external object is symbolically taken in & assimilated as part of the patient.
(Intrapsychic) Defence
Keeps the good and bad separated.
Get rid of unmanageable affects: treater better equipped to cope & becomes a container for the patient's projections.
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Operates unconsciously with compelling force |
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Projection: Patients project into a staff member disavowed feelings. They react to the staff member as if the staff member really is motivated by the disavowed feelings. The staff member is coerced into complying with assigned roles. |
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Countertransference: Staff experience emotional reactions to the patient as if they are people from their past. |
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Advantage of working in the context of an inpatient treatment team is that staff members can help one another distinguish CT patterns from those that are coerced (projective) identifications |
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3 step process (Kernberg): |
Patient projects a self-representation (self fragment) onto a staff member.
The staff member unconsciously identifies with what is projected & begins to feel or behave like the projected representation (fragment) in response to interpersonal pressure exerted by the patient.
The projected material is psychologically processed & modified by the treater, who returns it to the patient via re-introjection.
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Unconscious process employed automatically by a patient for emotional survival, to ward off destructiveness, where patient perceives individual staff in dramatically different ways, treats them according to projections & staff react accordingly |
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Staff find themselves assuming & defending highly polarised positions against one another with a vehemence out of proportion to the importance of the issue |
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Staff may become puzzled by disparate descriptions/ perceptions of the same patient |
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PI is the vehicle that converts intrapsychic splitting into interpersonal splitting |
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There is often a kernel of reality in the assignment of staff members - the cleavage is usually between treaters who emphasise the administrative frame of reference (what's good for the group) & those who emphasise the individualistic came of ref (based on what's good for the patient) |
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Direct disavowal of traumatic sensory data |
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Defence against the external reality of the world when that reality is overwhelmingly disturbing |
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Patients continuously test staff to see whether they will be different from previous figures. |
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The capacity to allow oneself to be "sucked in", but only partially, enables treaters to gain an empathic understanding of the patient's relationship problems |
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Staff should expect to experience powerful feelings that can be used as diagnostic & therapeutic tools |
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There is a difference between having feelings & acting on them |
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Discussing feelings will enable staff to approach the patient more objectively as the treatment progresses |
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This will reduce CT identification & assist staff to clarify patient's distortions |
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Denying feelings of CT hatred, anger & disgust may lead to non-verbal communications. Patients are adept at detecting these & as a result becoming more paranoid. Also, patients would receive the message that such feelings are unspeakable & must be avoided at all cost |
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Break the vicious cycle by understanding the interpersonal process rather than automatically joining the dance |
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If the treater is overcontrolled (overdefended against emotional reactions to the patient) then the assessment process of delineating internal object relations will be flawed & the treatment will be a charade |
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A sense of objectivity is an important ideal to strive towards, but is unreachable expectation early in treatment |
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Familiarity will help pinpoint deviations from characteristic patterns of relationships with patients |
Why does the patient need to evoke that reaction in you?
What is he/she repeating?
What figure in the patient's past are you identifying with?
How can we use the feelings the patient evokes in you to understand how his spouse & friends react to him/her?
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Education |
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Recognise early so it will be less entrenched & more amenable to change |
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Containing rather than acting on |
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Continuously monitor to prevent it from destroying treatment, devastating morale & irreparably damaging inter-staff relationships |
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Regular & frequent staff meetings |
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Spirit of open communication |
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Integrate the external objects: staff member identified with the good object meet jointly with the treater identified with the good object ---> conveys message that negative feelings can be contained without disastrous consequences |
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Idealised member should not assume condescending attitude, but all must swallow pride, empathise with fellow members' feelings & perspectives, remain collaborative |
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All parties should approach each other with the assumption that they are all reasonable & competent clinicians who care about the patient's welfare |
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Each staff member holds & should bring their piece to the puzzle so that the whole becomes more clear |
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Treater is uncharacteristically punitive |
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Unusually indulgent |
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Defends a patient against critical comments from other staff |
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One staff member believes no one else can understand the patient |
