Applying Psychoanalytic Thought to Contemporary Mental Health Practice

Paul Ian Steinberg

• Publisher: Routledge
• Year: 2021
• Print ISBN: 9781032060705
• eBook ISBN: 9781000486315
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Advances in psychoanalytic theory and technique can be usefully applied in virtually all psychotherapeutic settings, as well as in the management of patients in many nonmental health settings, to enhance understanding of patients. In this book, Steinberg reviews a collection of his own essays, incorporating developments in psychoanalytic theory and new ideas since his essays were published. Chapters clearly describe the evolving psychoanalytic approaches to treatment and illustrate how to use psychoanalytic concepts when working with patients.

A variety of clinical situations are covered, including group psychotherapy, partial hospitalization, and individual psychotherapy. This book provides the foundation of analysis and offers varied clinical experiences appealing to a wide range of practitioners and case examples offering descriptive details and interventions.

This book will be essential reading for all mental health professionals wanting to improve their working relationships with patients.

Part B

Group Psychotherapy and Partial Hospitalization Programs

DOI: 10.4324/9781003200581-6

One of the benefits of working on a team in a program or psychotherapy group is that two or more heads usually are better than one. If, for example, one therapist or leader of a program is unable to effectively respond to something that transpires in a group, another may be better able to. For example, in our day treatment program (DTP), once an individual with a severe personality disorder begin making disparaging remarks about the DTP, indicating how outdated our psychoanalytic approach was, going on at length about this. He had spent three months in DTP doing very little that could be called psychotherapeutic work. I thought angrily, like a cartoon character, “Why you little …,” and felt like wringing his neck, but couldn’t think of something appropriately therapeutic to say.

My thinking was interfered with by my anger. In retrospect, this probably gave an indication of how angry the patient was and also perhaps a hint about how his anger derailed his own capacity to think. However, my team leader, whose thinking wasn’t interfered with at this moment, lightly suggested that the patient should consider how important the issue out-of-date thinking was for him, implying that his thinking was out of date in terms of being quite primitive and childlike. He gave a big smile, showing that he understood what she was getting at, implicitly agreeing with her. Due to some vulnerability of mine, that day I was only able to respond with anger, and not use what the patient said in a way that was potentially helpful to him, supportive of our program, and potentially useful in helping other patients to engage with what was going on. So it was good that there were several therapists in this large (40+ patients) group, and one was able to respond effectively.

This is also a good example of how one must be patient with oneself, whether performing individual or group (or, for that matter, family or couples) psychotherapy. What might be the best response you can think of may not occur to you in the heat of the session. In fact, in my experience, the more pressure one is under, the harder it is to think. Fortunately, in our work, there often is a second chance to make the point that eluded one at the first opportunity. It is possible to persecute oneself for not thinking of it straight off. A more constructive response is to consider what was going on in the session that may have prevented one from thinking of it at the time, and whether something was going on in one’s personal life that may have interfered with one’s thinking at the time. It helps to accept that sometimes it takes our unconscious minds time to come up with the most felicitous ideas.

For more on psychoanalytic approaches to inpatient and day hospital settings, see Chapter 16, Psychoanalytic approaches integrated into day treatment and inpatient settings, of my Psychoanalysis in Medicine: Applying Psychoanalytic Thought in Contemporary Medical Care (Steinberg, 2021).

Reference

• Steinberg PI (2021). Psychoanalytic approaches to psychosomatic medicine. In Psychoanalysis in Medicine: Applying Psychoanalytic Thought in Contemporary Medical Care. London and New York: Routledge, 95–106.

4Danger from Within

Threats of Violence in Group Psychotherapy

DOI: 10.4324/9781003200581-7

In this chapter and Chapter 5, it is the psychoanalytic understanding of projective mechanisms and the focus on countertransference considerations that informs the management of the very disturbing experience of threats in the context of group psychotherapy.

Threats of violence are an aspect of group psychotherapy that leaders of groups find threatening and might prefer to ignore. The sparse literature regarding violence and threats of violence in group psychotherapy may reflect the anxiety of practitioners regarding this subject, similar to the paucity of literature on countertransference in the early decades of psychoanalysis. This chapter deals with our experience of threats of violence in psychotherapy groups in the psychiatric day treatment program (DTP) of the University of Alberta Hospital. DTP is led by a clinical coordinator (psychiatrist) and a team leader (nonmedical mental health professional). Threats of violence do occur in DTP, which admits individuals with severe personality disorders (Piper et al., 1996). Most of DTP’s patients have a diagnosis of narcissistic or borderline personality disorder or both, and a significant number have antisocial traits. Occasionally, we admit an individual with antisocial personality disorder. One of the difficulties of responding to situations involving threats of violence is the fear and anxiety engendered. The fear is related to the physical danger presented by the threat. The anxiety is related to concerns about how therapists can function in a very difficult and relatively unfamiliar situations. When discussing fear and anxiety being engendered in psychotherapy situations, especially when there is a question of violence, the concept of projective notification arises. To what extent are group members and therapists intended to feel afraid or anxious? To what extent might this be an unconscious communication of the threatening individual’s own fears?

The observations, conclusions, and interventions discussed here in the context of a partial hospitalization program apply, I believe, to all psychotherapy groups and, for that matter, to all clinical venues.

Literature Review

I found no specific references to threats of violence in the group psychotherapy literature. In contrast, there is a substantial literature on patient assaults of therapists and mental health personnel (Beck & Roy, 1997). Newman (1997) examines characteristics of emotional abuse experienced by therapists and presents approaches on how to cope with it. He deals with behavioral approaches that allow clinicians to maintain professional decorum with behavioral techniques such as cognitive rehearsal, rational responding, and assertiveness, as well as encouraging judicious use of documentation and supervisory consultations. He deals neither with group psychotherapy nor psychodynamic aspects of predicting or responding to threats. Koopman et al. (1998) describe clinical administrative staff reporting greater acute stress reactions than residents, interns, or research staff after a threatening episode at an outpatient psychiatric clinic. Acute stress symptoms were strongly and positively related to both functional and dysfunctional behavioral change. This article did not deal with group psychotherapy or make suggestions regarding prevention or management of threats.

An observation scale to record aggressive behaviors, defenses, and interventions that occur during a psychotherapy group has been developed (Lanza et al., 1998). The development of the scale appears promising, but the article’s discussion of clinical relevance was unfortunately very brief. In this longitudinal study, the rate of assaults on staff on wards taking part in training to learn strategies for coping with violent psychiatric patients was 31% lower after implementation of training. Eight steps for developing a violence prevention program are described.

Case Example

The following case example is derived from DTP, an 18-week, all-day psychodynamic group psychotherapy-based partial hospitalization program. Our patients suffer from severe personality disorders and comorbid Axis I disorders, especially mood disorders. They attend a variety of unstructured and semi-structured groups four and a half days a week. Confrontation and interpretation are the chief techniques employed. The unstructured groups include a large group in which all patients and therapists attend, and smaller groups in which patients are divided according to their phases of treatment. Each day starts with Large Group, an unstructured group designed to reduce splitting among staff and patients. The semi-structured groups deal with themes such as identity, self-respect, self-discipline, and close relationships. The day ends with a social or recreational group where patients can socialize and inevitably experience difficulties in socialization, which can be discussed in other groups.

Eighteen weeks appears to be a minimum time in which to have a significant psychotherapeutic effect on these patients, who are often limited in psychological mindedness and motivation for treatment. The latter factors, of course, have become important foci for psychoanalytic and psychodynamic psychotherapeutic treatment in recent decades, rather than being relative contraindications for treatment, as they once were considered. Regarding this, DTP patients with significant personality pathology have similar difficulties to the patients described at the beginning of Chapter 3. Supervision for DTP therapists consists of meetings of co-therapists after groups, weekly hour-long staff relations groups (SRGs) (O’Kelly & Azim, 1995), and unscheduled discussions among the therapists, the team leader, and the clinical coordinator as needed.

Camille is a 24-year-old, divorced, unemployed, casual clerical worker who is physically tall and large, with a very imposing presence, which can become threatening when she is angry. When she becomes angry, she quickly is enraged; she appears not to have an emotional “rheostat” to enable her to regulate her temper. Individuals with significant personality pathology often are deficient in affect regulation. Such people are emotionally volatile, frequently and easily express intense affects such as rage or despair, and often receive a diagnosis of borderline personality disorder. The capacity to regulate affect is not inborn; observation of infants in the first weeks and months of life illustrates this. This capacity gradually is internalized from mothering figures as they soothe the baby in any number of ways, including physical care, gentle talking, and labeling the infant’s affects. This gradually leads to the infant to being able to identify the latter himself, an important part of the development of the capacity to think. To the extent that an infant does not experience wholesome and competent containing by a mothering figure, many important personality qualities, including affect regulation, will not develop in a satisfactory manner. This leaves the individual seriously disadvantaged in terms of not being able to contain himself adequately when it is important to do so, for example, in public, or when he is angry with his boss. This type of individual will be more likely to be overwhelmed by painful and frightening affects and to tend to develop defenses (that can be maladaptive) in an attempt to avoid experiencing these affects. The associated significant disadvantages include being emotionally cut off and not be able to enjoy intimacy with others and an inability to use affects for their signal function, that is, warning that there may be danger in the external world or when something internally is disturbing them and needs their attention.

Camille was brought up in a family characterized by abuse and neglect. Her father, an alcoholic who physically abused his wife and five children, was never involved in positive interactions with them. A history of physical abuse can result in internalizing a destructive object. That is, an unconscious image of the destructive father develops in the child, which is accompanied by both a destructive attitude to oneself and to one’s relationships. This may be expressed in a harsh superego, that is, a harsh and punitive attitude toward oneself and a tendency toward harshness in one’s relations to others. The harsh attitude toward oneself may be expressed in using others to treat oneself harshly, for example, by undue deference or submission to a partner, friend or even stranger, which is in the realm of masochistic pathology. In Camille’s case, she seemed to defend against feeling helpless with and vulnerable to this internal object by projecting these feelings (and self-image) into others, as we shall see.

Camille’s mother was timorous and ineffectual, offering a bit of affection, but too preoccupied by her own difficulties to be very available for sharing positive experiences. This type of experience with mother can result in an identification with mother, with the development of a frightened, helpless self-image, characterized by deficient personal agency and an inability to take the initiative in pursuing one’s interests. As mentioned above, this self-image may be defended against by projecting it into others, identifying with an abusive parent. An older sister offered more in the way of parenting. Camille’s father, in drunken rages, used to interrupt beating her mother to attack the children. Camille remembers being thrown across the room. Camille had no known previous history of violent behavior herself.

Camille had been attending DTP for two months. One day, she was clearly angry and started talking in Large Group even before people had sat down. This developed into a tirade against several patients whom Camille felt were talking about group issues prior to the beginning of the group. When Camille became verbally abusive and threatening, the psychiatrist interrupted her, indicating that this behavior would not help her and was unacceptable in DTP. Camille said that she considered bringing in a gun and shooting some people, and angrily stormed out of the room, after telling the psychiatrist, “Watch your back.” The psychiatrist, after some moments of hesitation and fear, left to ascertain whether Camille had left the building and then returned to the group. Patients’ associations initially involved their being reminded of their own anger, which sometimes felt like murderous rage. As the psychiatrist became aware of his fantasies of Camille returning with a gun and shooting members of the group, himself in particular, the patients became increasingly anxious, asking for reassurances that this would not happen.

The psychiatrist then called hospital security who involved the police. He certified Camille for emergency assessment regarding dangerousness to others and had the police search her house for weapons. The other patients continued working in Large Group. They talked about their anger at Camille and how her anger reminded them of their own rage and the rage of others, frequently their parents, to which they had been exposed. The therapists were more comfortable once they knew that the security department and the police had been contacted. However, they remained quite anxious during the rest of Large Group, feeling there was no guarantee that Camille would not return with a gun. Not until later was it learned that she had been apprehended, brought to an emergency department, and admitted to a psychiatric hospital.

Camille appeared to have internalized an object representation characterized by abusiveness, hostility, rage, violence, destructiveness, and a lack of tender feelings or warm relatedness. Her self-image appeared to be that of a helpless, frightened, abused, and neglected child. Nonviolent boundary violations by other patients seemed to have precipitated Camille’s threat. These interactions may have brought Camille’s self-image closer to conscious awareness, both in terms of these violations and the fact that they were handled nonpunitively. Camille dealt with this increased awareness by projecting her frightened child self-image onto other group members, identifying with her destructive internalized object, and treating group members as her father treated the rest of the family. That is, Camille appeared to defend against experiencing herself as a helpless, abused, neglected, frightened child by evoking these feelings in others, an example of projective identification.

When one is threatened under unfamiliar circumstances, it is difficult to feel secure that one is responding most appropriately. In retrospect, the therapists of DTP thought that rather than merely ensuring that Camille had left the building, the psychiatrist should have involved hospital security and the police immediately. He believed that when Camille left, she was deliberately trying to frighten the members of the group, and th...

Table of contents

• Cover
• Endorsements Page
• Half-Title Page
• Title Page
• Copyright Page
• Contents
• Publication Acknowledgments
• Acknowledgments
• Foreword
• Introduction
• Part A Psychoanalytic Understanding
• Part B Group Psychotherapy and Partial Hospitalization Programs
• Part C Individual Psychoanalytic/Psychodynamic Psychotherapy
• Conclusion
• Glossary
• Index