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Assessment, Trauma, Narcissism

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Chapter Three: The consultation

Helen Alfille Karnac Books ePub

When considering what happens in a consultation, it is very important to know for whom we are doing this assessment. Are we assessing for an organization, for ourselves, or to make a referral? If an assessment is made by a hospital or clinic, there are certain constraints of time and the consequent intensity of work possible, but, on the other hand, there may be the benefit of input by the whole psychiatric team, which would be particularly helpful for severely disturbed patients. If, however, we are looking for a patient for a trainee psychotherapist, we would take extra care in exploring certain areas of the patient's psyche. We would be particularly concerned about ego strength, ability to commit, addictions, suicidal tendencies, and, of course, psychosis.

When does the assessment start?

Is the initial phone call important? Greenson (1967) feels that the initial phone call should be a good example of any future therapeutic work. This entails the analyst's careful listening and interest in the patient, so that he feels that his concerns are being taken seriously. The transference continues to develop as information is conveyed by the voice and accent of the assessor. Patients can be put off, or made more or less anxious, by the therapist's manner. For example, an American analyst chose to take a call from someone requesting an assessment during a patient's session. He was curt with the new referral and succeeded in making both patients feel rejected. We emphasize that a patient should feel that an analyst is as concerned about his welfare on the telephone as he would be in the consulting room. For instance, Greenson quotes a seventy–eight–year–old man whose psychiatrist had died. He had read about psychoanalysis and Greenson, and had rung for an assessment session. Greenson explained that psychoanalysts worked rather differently and he would like to refer him to a trusted psychiatrist colleague. He left the choice to the patient, however, who accepted Greenson's advice and was very pleased with the referral. Another therapist had the experience of being telephoned on a Sunday for an assessment. The caller was in a very difficult domestic situation but it transpired that she already alerted many professionals to her situation and was receiving a great deal of help. To offer an assessment would have added to the confusion of her splitting and reinforced her fantasy of a magical solution rather than encouraging her to use the help she had already mobilized.

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5 - Working Over

Peter Hobson Karnac Books ePub

CHAPTER 5

Working over

R. Peter Hobson

As a consultation proceeds, things that have happened at the beginning of the session need to be worked over, as patterns of anxiety and conflict, defence, and relatedness repeat and resurface in different forms, again and again. Each time they do, a therapist's picture of the patient acquires depth. Whatever disturbance and distress erupted at the commencement of the interview is now set in the context of other, often more reflective states of mind that the patient may bring to bear on making sense of what his or her feelings mean. The picture is also enriched by what the person recounts about his or her past and present life.

In psychotherapy, as in life, all is in movement. A particular form of movement is especially important as an expression of a patient's ways of dealing with anxieties and conflicts stirred by an intimate relationship. This kind of movement involves shifts in intersubjective engagement. Such shifts entail that patient and therapist feel how things alter in relation to one other. Although the determinants of the respective positions of therapist and patient are complex, the attitudes of each have a shaping influence on the attitudes of the other. Psychotherapists need to hone their awareness of how they are being induced to feel things, as well as how their own attitudes and interventions influence a patient's state of mind.

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Chapter Four: Transference and countertransference in the assessment consultation

Helen Alfille Karnac Books ePub

… transference refers to the relationship that develops between patient and analyst as a result of projection onto the analyst of feelings, thoughts, and attitudes that derive from the childhood past of the patient and from his relationships to important objects that have undergone repression. [Shapiro, 1984, p. 13]

Waelder (1960) emphasizes that the chief feature of transference is the effort by the patient to persuade the analyst to behave as if he were an object from his past. Transference can be seen as a ubiquitous phenomenon, as all our relationships are coloured by our earliest experiences of object relations. “One might say that this is the transference of everyday life” (Shapiro, 1984). It follows that transference reactions occur in all patients undergoing psychotherapy and, therefore, it is of the utmost importance to be sensitive to the transference–countertrans–ference manifestations within the assessment exchange. Having said this, it is important to stress that Freud used this concept as a particular phenomenon occurring in analysis and reaching its fullest expression in the transference neurosis. The transference which develops in treatment manifests as a “stuck” transference, which is different from the transference reactions of everyday life. According to Freud, impulses that have never before been conscious may surface for the first time. If patients are caught in this kind of transference in therapy, for example, “in love” or “in hate”, it is a resistance which Freud initially saw as an obstacle to the treatment. Later, in his paper “The dynamics of transference” (1912b), he describes the process as “This struggle between the doctor and the patient between intellect and instinctual life, between understanding and seeking to act, is played out almost exclusively in the phenomena of transference”. It became a central dynamic in the treatment process. This is why it is so important for the assessor to be sensitive to these nuances, because it gives a taste of how the transference relationship may develop during the course of therapy. Some practitioners differentiate between the first piece of evidence of transference seen in an assessment consultation, which they term “false transference” (Bird, 1972; Zetzel, 1970) or “pre–treatment pseudo–transference fantasies” (Zetzel, 1970) and the gradual development of the transference in treatment. The sort of things we are looking for as transference phenomena would obviously occur more clearly in the ongoing therapeutic relationship, but some may be evident in the assessment session.

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Medium 9781855756663

CHAPTER 7: THE HUNGRY SELF: WORKING WITH ATTACHMENT TRAUMA AND DISSOCIATION IN SURVIVORS OF CHILDHOOD ABUSE

Sarah Benamer Karnac Books ePub

Sue Richardson

This paper explores some features of attachment-based work with people with dissociative conditions. It describes work T with a very wounded and vulnerable part of the self within a client, “Sally”. It concludes that the capacity for repair does not rest on the severity and chronicity of abuse or developmental dependency on the abusers, but rather on establishing a secure therapeutic base from which a relational bridge (Blizard, 2003) can be built and some communication established across dissociative barriers.

Sally suffered serious attachment trauma, including emotional and sexual abuse from early childhood. She has had considerable difficulty in forming supportive companionable relationships and her relational experience has been of dominance and submission (Heard & Lake, 1997). She is also in poor physical health, much of which arises from long-term anorexia.

At the beginning of therapy, the wounded, vulnerable part of Sally was in a double bind, caught between the longing for care and the fear of approaching a care-giver. Sally regarded the emotional and physical hunger of this part of the self as dangerous and intolerable. In turn, the hungry self had become a separate,dissociated self, of whose needs and responses Sally was persistently dismissive.

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8 - Trauma

Peter Hobson Karnac Books ePub

CHAPTER 8

Trauma

Joanne Stubley

My aims in this chapter are twofold. First, I consider how a brief series of consultations might be of value for individuals who present with trauma. Second, I discuss how the psychological effects of trauma yield insights into the workings of the mind. Such insights are relevant for therapeutic work beyond that with traumatized patients.

I begin with a clinical description, but not of someone who came for consultation.

A person's story of trauma

A young college student, walking through a park on the way home from a party, is brutally raped. In the following weeks two other women are attacked in a similar manner, but they lose their lives at the hands of their attacker. The college student experiences post-traumatic stress reactions in the form of nightmares, flashbacks, difficulty sleeping, feelings of isolation and distance from friends and family, emotional numbness, and withdrawal.

Unable to return to classes, the student leaves college and returns home. There she finds it difficult to speak about her experiences. She finds herself embroiled in pointless arguments and disputes within the family. She breaks up with her former boyfriend and sees many of her old friends drift away. Eventually she begins to pick up the pieces of her life, restarting college in another town.

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Medium 9781855755406

CHAPTER SEVEN: The origins of rage and aggression

Neville Symington Karnac Books ePub

“Paradoxical as it may sound, I must maintain that the sense of guilt was present before the misdeed, that it did not arise from it, but conversely—the misdeed arose from the sense of guilt. These people might justly be described as criminals from a sense of guilt”

(Freud, 1916, p. 332)

It is a mistake to think that psychoanalysis has one theory. Psychoanalysis is a clinical methodology that encompasses a wide range of theories. Nowhere is this more evident than when psychoanalysts start to discuss the cause of aggression. At its most simple there are two theories. The first states that aggression arises when a human being’s basic needs are frustrated. This theory is based upon the homeostatic theory of motivation. This states that the organism has a built-in tendency to equilibrium, to homeostasis; when inner tension arises, the organism is programmed to reduce that tension through incorporating food, water, or finding an object that will satisfy a sexual need. Aggression arises when one of these needs is frustrated. Aggression is therefore a reaction to frustration.

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CHAPTER THIRTEEN: Narcissism: a reconstructed theory

Neville Symington Karnac Books ePub

“Mr. Luzhin was morbidly fond of admiring himself. He had a tremendous respect for his own intelligence and abilities, and sometimes, when alone, he spent hours admiring himself in the looking-glass”

(Dostoyevsky, 1966, p. 322)

Introduction

In a recent book I have sketched the outline for a new theory of narcissism. In that book I give many clinical examples, ideas on how narcissism can be reversed, and the relation of my theory to those of some others. I also make extensive use of Tolstoy’s Anna Karenina to illustrate some of the central phenomena of narcissism. n this short article all this has been mercilessly cut out and I give here only the skeleton of my theory. What the reader will get from this article is the structure of the theory.

Resolution of contradictions in psychoanalytic theories

Within psychoanalysis there is a strong reluctance to throw out any theory. The result of this is that when a new theory is proposed that is in contradiction to an accepted theory the two are left, one superimposed upon the other. We operate then with a split that leads to obfuscation. There are numerous examples of this, but I shall just give one. Fairbairn radically re-cast Freud’s libido theory and in his model he rubbed out the Id in Freud’s Structural Theory. Many analysts who follow Fairbairn accept his model without rejecting Freud’s Structural Model. This means that Fairbairn’s theory has not been understood. To make sense of the theory that I am proposing, and if it is to be effective in clinical work, it is necessary to ditch several aspects of received theory. A reader may disagree with my theory, or part of it, and reject it—that is all right, but if you accept it then you will have to do a lot of work in letting go of some theories which are contradicted by what I am putting forward.

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