Boundary issues and multiple relationships: Fantasy and reality. Professional Psychology: Research and Practice, 38 4 , — Informed consent: Too much of a good thing or not enough? Professional Psychology: Research and Practice, 38 2 , — Behnke, S. Psychological ethics and national security: The position of the American Psychological Association.
European Psychologist, 11 2 , — Chennevelle, T. HIV, confidentiality and duty to protect: A decision-making model. Cornish, J. Perspectives on ethical practice with people who have disabilities. Professional Psychology: Research and Practice, 39 5 , Cottone, R. Ethical decision-making models: A review of the literature.
Journal of Counseling and Development, 78 3 , — Donner, M. Balancing confidentiality: Protecting privacy and protecting the public. Professional Psychology: Research and Practice, 39 3 , — Drogin, E. Professional Psychology: Research and Practice, 41 3 , — Fisher, C. The APA ethics code and the need for balanced confidentiality and disclosure decisions in psychotherapy. Internet-mediated psychological services and the American Psychological Association ethics code. Fisher, M. Protecting confidentiality rights: The need for an ethical practice model. American Psychologist, 63 1 , 1— Professional Psychology: Research and Practice, 40 1 , 1—7.
Gabbard, G. Professional boundaries in the era of the Internet. Academic Psychiatry, 35 3 , — Gallardo, M. Ethics and multiculturalism: Advancing cultural and clinical responsiveness.
Professional Psychology: Research and Practice, 40 5 , — Goodyear, R. Ethical issues in the supervision of student research: A study of critical incidents. Professional Psychology: Research and Practice, 23 3 , — Gottlieb, M. Avoiding exploitive dual relationships: A decision-making model. Psychotherapy, 30 1 , 41— Is there a slippery slope? Considerations regarding multiple relationships and risk management.
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Professional Psychology: Research and Practice, 40 6 , — Hadjistavropoulos, T. Making ethical choices: A comprehensive decision-making model for Canadian psychologists. Canadian Psychology, 41 2 , — Hansen, N. Navigating the nuances: A matrix of considerations for ethical-legal dilemmas. Professional Psychology, 30 5 , — Heilbrun, K. Involuntary medication, trial competence, and clinical dilemmas: Implications of Sell v. United States for psychological practice.
Professional Psychology: Research and Practice, 36 5 , — Standards of practice and care in forensic mental health assessment: Legal, professional, and principles-based consideration. Psychology, Public Policy, and Law, 14 1 , 1— Johnson, M. The need for continuing education in ethics as reported by rural and urban mental health care providers. Professional Psychology: Research and Practice, 37 2 , — Johnson, W. He collects together the evidence for this and presents the ways in which it's strongly beneficial effects promote health in patients of different kinds, including those suffering from depression, anxiety, panic, somatoform disorders, eating disorders, substance-related disorders and personality disorders.
He writes that 7 features reliably distinguish psychodynamic therapy from other therapies. These 7 features largely determine the illnesses that can be helped by it, although schizophrenia and schizoaffective disorder are not included in his analysis of the technique. The 7 features include a focus on affect and expression of emotion, exploration of attempts to avoid distressing thoughts and feelings, identification of recurring themes and patterns, discussion of past experience, focus on interpersonal relations and on the therapy relationship, and exploration of fantasy life.
Shedler demonstrates that the effect sizes of psychodynamic therapy compare very favourably with all other psychological therapies and with antidepressant medication, and ventures to assert that several other psychological treatment techniques utilize without acknowledgement the benefits of psychodynamic techniques; indeed he suggests that the efficacy of these other psychological treatments such as CBT are as effective as they are because of the loan they have taken from psychodynamic ideas.
There is, however, a distinguished history of the application of psychoanalytic psychotherapy for schizophrenia. Each author contributed to theoretical concepts, mooted psychoanalytical mechanisms underlying symptoms, and to clinical practice. Freud originally held that the narcissism of schizophrenic patients prevented them from being able usefully to relate to the analyst and so develop the therapeutic relationship of transference with him or her. For this reason, Freud believed that schizophrenic patients could not be treated with psychoanalysis. Melanie Klein, however, discovered that both positive and negative transference could be established with them [ 2 ].
Three of her distinguished students, Wilfred Bion, Herbert Rosenfeld and Hanna Segal went on to work with schizophrenic patients, and each of them made their own contributions to the field. Bion believed that, ignoring the effects of the external environment, the schizophrenic personality depends on four factors: i a conflict that is never resolved between life and death instincts ii a preponderance of destructive impulses iii hatred of external and internal reality and iv a tenuous but tenacious object relationship [ 3 ].
If the psychoanalyst bears these features in mind he may understand better how to tackle the relationship difficulty in the consulting room. Bion also believed that psychotic patients possess a non-psychotic component of their personality [ 4 ] which offers hope to the therapist in accessing parts of the patient which, if modified, could lead to their decreased subjection to psychosis. Melanie Klein identified the importance of projective identification in the schizophrenic mind, that is, casting out one's bad feelings into another person and sometimes trying to control this person.
Bion continued this idea. As he wrote, "Projective identification of conscious awareness and the associated inchoation of verbal thought is the central factor in the differentiation of the psychotic from the non-psychotic personality" [ 3 ]. Rosenfeld worked with narcissistic patients, and came to believe that there are two forms of narcissism, destructive and libidinal narcissism [ 5 ].
He also believed that there are several types of projective identification, for example one form is used for communication, one tries to unburden the self of unwanted parts, and another tries to control the analyst's body [ 6 ]. Hanna Segal differed from Rosenfeld's views on narcissism, believing that only destructive narcissism exists [ 7 ], but she agreed with him that projective identification can be used by schizophrenic patients to evacuate unwanted parts of the self into other people [ 8 ]. More recently, Richard Lucas devised the concept of "The Psychotic Wavelength", where the therapist has to bring himself into the patient's arena of thinking by conceptualizing concretely [ 9 ].
Marcus Evans has also written about this clinical technique of working with psychotic patients [ 10 ]. Leslie Sohn accepted that psychotic patients have a non-psychotic part of their mind [ 11 ], and opined that a mental state examination should be performed every five minutes when giving psychotherapy to a schizophrenic patient to check for psychotic elements that may be currently operating.
Murray Jackson has strongly upheld the application of psychoanalytic principles to the treatment of mental illness including schizophrenia, and understood how it should be applied. For example, he recognised that therapy for severely disturbed patients should always be planned on a long term basis [ 12 ]. All Psychiatrists, and many Psychoanalysts working with psychotic patients, accept the unassailable place of medication in their treatment and management.
Invaluable in the early stabilization of patients when they newly arrive in a psychiatric ward, but only given when the patient has been listened to and talked to as much as possible to gain knowledge about their individual mental state, medications then control psychotic symptoms to a greater or lesser extent. Full benefit from them may only become apparent after several weeks' use. Their correct use is to help the patient to tolerate their mental life, dealing with hallucinations and delusions as far as possible and freeing up the non-psychotic part of the patients mind into becoming accessible for the therapist to relate to, usefully.
The therapist becomes able to uncover more underlying aspects of the patient's mind by gentle probing and a tactful approach when speaking with the patient once the psychotic symptoms no longer interfere with communication. The therapist may discover useful aspects of the patient's thinking that can be used in their treatment programme, especially if the patient regards them favourably. The patient's personality may blossom when the symptoms are controlled, if they live within a loving family or, more usually, the patient may continue to suffer psychologically from the causative psychogenic factors in their life.
But their requirement for medication is almost always long term. Non-compliance is unfortunately quite common, and if persistent then injections are usually resorted to therapeutically in place of pills. As mentioned above, strictly applied psychoanalysis is too stringent and stressful for a schizophrenic or schizoaffective patient to be able to benefit from it. It requires a much stronger sense of self or ego functions than a schizophrenic patient possesses.
A schizophrenic patient would probably be unable to understand their role in a classical psychoanalysis. Equally, supportive psychotherapy would not be exploratory or intensive enough to effect the changes at a deep level sometimes sought by a schizophrenic patient. Fundamental self-scrutiny and discovery generally only result from analytic therapy, but this can, indeed, be performed and bring healing even in schizophrenic patients. Whether or not a particular patient does seek radical healing has to be determined from what is known about them in their earlier history, their background in studies and work, and their expressed views while mentally ill but calm.
Psychoanalytic psychotherapy is both supportive and analytical, and therefore in capable hands has the potential to resolve the patient's mental pathology while supporting them psychologically. Michael Robbins, in Massachusetts, USA, has developed a psychoanalytic psychotherapy technique for treating schizophrenic patients. The patients he has treated all conform to the DSM-III-R symptom classification of schizophrenia, most often paranoid schizophrenia, and their ages range from late teens to their twenties. His personal portfolio of 18 patients, together with other patients, is an excellent example of pioneering work, which he has written up in his book "Experiences of Schizophrenia" and many papers, and in which he provides rich details of his clinical findings, views and conclusions [ 13 ].
His lifetime's work relates his successes as well as those of his cases that did not succeed in alleviating the patient's distress. He looks objectively at the possible reasons that might account for the failures, and has been able to describe half of his patients, 9 out of 18, as having had "positive outcomes", 6 of these being "very successful". A further patient's therapy has been written up in his paper "The successful psychoanalytic therapy of a schizophrenic woman" [ 14 ]. He is a trained Psychiatrist and Psychoanalyst, and has been able to gain understanding of schizophrenia and schizophrenic patients at a deep level.
He adheres to a hierarchical understanding of the illness that involves molecular biology, neurobiology, neurochemistry, psychoanalysis, interpersonal psychology, family systems, sociology and cultural anthropology.
Encyclopedia of Psychotherapy
Like almost every clinician who works with schizophrenia, he acknowledges the place of medication in the treatment of his patients, who have been based at the Maclean Hospital in Massachusetts while they received psychoanalytic treatment from him in his consulting room. In his book he expresses intense gratitude to the staff there for their management of his patients, as is the case for most therapeutic clinicians who work with very mentally ill individuals who require hospitalization while receiving their treatment. One of his remarkable results has been that he has been able to stage the progress in treatment of all of the patients whom he has treated, a sequence of 7 Stages Table 1.
All of his patients follow this process, even if they were not able to complete their therapy. His approach has been to deliver psychoanalytic psychotherapy to all his patients, and to observe how they have progressed in his care. He writes of the healing power of love, and with this ethos has nurtured all of his patients as far as they were able to proceed in treatment with him.
The full therapy process involves two major phases; initially the patient is very ill and can only relate to him from their unhealthy, schizophrenic perspective. After this the patient goes through the second phase, that of relating more normally to the analyst, in which phase the Stages of the process lead to therapeutic termination. Table 1: Stages in the psychological resolution of schizophrenia. View Table 1. When the patient enters therapy they are invariably severely afflicted mentally.
They have been unable to develop normally, whatever their individual experiences have been, and their minds are unhealthily distorted so that they have become unable to function properly where they have found themselves trying to live. As a result, they find interaction with others very difficult indeed, and experience great if not impossible difficulty in asserting themselves as they would like to in order to overcome the frustrations of one situation after another.
Relating to their analyst is no exception. Apart from the anxiety that this unusual situation causes them, where they are, and where they experience being under the scrutiny of a professional person, they generally suffer acute difficulty in comprehension and emotional pain at some level during their clinical interactions.
Dr Robbins describes this relationship, in Stage 1, as "Protopathosymbiosis" or "parasitism". The patient contributes little to the relationship, being completely dependent upon the analyst for steering it along therapeutic lines. The patient's identity is invested in her psychotic state and she is incapable of helping herself very much at this Stage. That she has turned up, and continues to turn up daily at her analyst's consulting room is as much as she can do for herself.
She has been selected for therapy because of previous evidence of stamina and achievement in her earlier life, but now she has disintegrated due to circumstance, and all of what is still healthy in her psyche, her non-psychotic mind, strains to co-operate with the analyst to move forward psychologically. Due to her efforts, she may succeed in engaging with the analyst. If she has given him a chance by listening to him and drawing some benefit from his words, she may develop for herself some lifelines of emotional security, good humour, tolerance, appreciation of his interest in her and absorb some of his tenacity for continuing with her sessions.
However, her sense of her individuality is threatened, because he may be saying things to her with which she disagrees but has to continue to listen to. This is hard for her. She may feel that some of her loyalties are threatened, but that she can do nothing about this, even apparently in her own self-defence. Most patients in this Stage, Stage 2, continue to assert their own, schizophrenic and ill, perspective, consequently finding the sessions irksome and annoying, frustrating and sometimes miserable.
She has become used to her own false assumptions, biased opinions, unrealistic expectations and possibly questionable family values. But the analyst must continue to assert reality to her. It is essential that if she is to become well she must renounce every part of the false world within which she has been living. She is probably unaware at the commencement of her treatment of just how distorted her schizophrenic thinking is. It is the distorted views, biased perspectives and egregious interpretations of reality which together largely underpin her schizophrenia or schizoaffective disorder, compounded by emotional difficulties, and probable slight brain dysfunction affecting her reward centres, executive function and cognition.
It is extremely taxing for her to attend her analyst, return to hospital for ward care, and return to her analyst the next day, 4 or 5 days every week for years between short breaks for holidays.
Her perspective on the world is extremely bleak, and she may at a deep level be extremely miserable. The hospital staff must be alert at all times on a continuous suicide watch, for her as for all their other patients. This is the main reason why patient selection for this treatment has to be so cautious, and why care by the hospital unit must be so effectively secure. Schizophrenia and schizoaffective disorder are life-threatening conditions, but this therapy can lower the suicide threshold for intervals of time during phases of growth in the treatment, and the hospital staff cannot always know, within their daily routines, exactly when these times are occurring.
Kindness and firmness are probably the nursing techniques that are most effective in sustaining patient morale, within the consistent environment and ambience of security. This relationship between the patient and her analyst, where the patient is very ill and trying to hang on to her sessions while feeling confused and misunderstood, except on the few occasions when her analyst says something to her which she understands clearly, and can accept without feeling threatened, is termed by Dr Robbins as "Pathosymbiosis".
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It spells difficulty for the patient, as outlined above. Psychotherapeutic subprocesses will not be available in any new social structure unless they are deliberately built in and trained for. I have already said how little education and training I believe is required—but it does require some. It will not occur if there is no training, effort, planning, and roles defined for it.
What is needed is the creation of new patterns, new roles which ordinary people can learn to adopt.
The role of a high school senior "older brother" described above is an example. Here are some other examples: In Illinois we have been planning to define and train some persons in the community as a special sort of community workers who work both in the hospital and in the community. They can therefore begin to work with patients still in the hospital, later meet them in the community to connect them with a new job, church group, living quarters, and social group. Because they work both places but belong to the community, these workers could easily return the patient to the hospital if necessary without losing contact with him.
They could therefore also try to get patients out into the community long before they are strictly speaking "ready for it," so that they can become ready. Still another pattern, one we have tried, Gendlin ; Rogers is "ward availability. Of course, among aides, nurses, O. We provided a "ward-available" person and found that less than half time 16 hours per week made quite a difference on a ward of 24 patients. Ordinary people can learn to be ward-available. Of course, if we put psychotherapy and community psychology together along something like these lines, we will have to contend not only with the prejudices and blind spots of community psychologists, but equally or [Page 70] more so with the prejudices and blind spots of psychotherapists.
Here are a few. Psychotherapists often believe that if you can't take a person on for good and ever, don't talk to him even for a few minutes. Yet we all know that one talk with a helpful person can help an incarcerated and isolated patient. Even a few minutes in which he finds himself "making sense" can be a major forward-propelling event.
Psychotherapists often believe that their skill requires so much training that none except themselves should be permitted to do anything like it. They often believe, too, that too much supervision will be needed, if new psychotherapy-like roles are defined for more ordinary people. Yet they also fear for their jobs.
But if we will need thousands of supervisory people, the well trained therapist will be more in demand than ever. Above all, clinical psychologists are trained to be office-bound, they are often intensely uncomfortable even in the waiting room, let alone in the community, or on an open ward, or in a block club meeting. But this discomfort is soon overcome, one need only be willing to be ill at ease and not useful for a short period during which one learns what is needed.
There are also theoretical prejudices to be overcome. For example, most therapists believe that therapy can do anything: if the patient is only made psychologically well, he will find a job, a wife, a home, friends, and so on. They believe that if only Ho Chi Minh and Johnson could sit down together with a therapist, they would soon "understand each other" and then we would have peace.
Not only does this miss the situational nature of "feelings" which I cited earlier, it misses the whole structural level entirely. One must realize that poor people have no purely psychological problems, they are confronted with a whole unlivable situation inclusive both of how it is and how they are. People who need jobs have to be helped with both as one unit, or they won't find or hold a job. There are economic, racial, community and family reasons why a man can't find a job.
There is a structural level of analysis.
Psychoanalytic theory - Wikipedia
Therapy does not solve economic problems. It doesn't solve structural problems. Take labor-management bargaining as another example of the structural level which psychotherapists so often ignore. Some thought that if a therapeutic sort of person were provided in a labor management dispute, this would help avoid a strike. But labor-management bargaining is a social process which has a certain structure as it develops over time.
The bargainers must begin by making nearly impossible claims. Then there must be a period of "floating a package" where the two sides feel each other out. An area of possible agreement is sensed and information is exchanged about what could or could not possibly be considered. When the two sides are very near agreement, then there must first be a crisis. Unless there is a crisis, neither side is sure it dragged the other side as far as it could, and the labor rank and file can't be sure they weren't sold out. If you place a therapeutic type of person into this situation, especially if he isn't aware of the pre-determined structure of the bargaining process he will prevent the process from happening properly, and there will be either no agreement, or one which neither side will eventually accept, and there will be a strike.
Douglas, Psychotherapy alone will not get patients out of the mental hospitals. For many years therapists in mental hospitals have discovered painfully that to get even one patient well, they have had to work with the patient, the aides, the nurses, the superintendent, the patient's family, the vocational people to help him begin to work when he "isn't ready," the social worker to discuss release when he isn't ready, the landlady in the community, the community's attitudes "He burned a barn down eight years ago, they don't want to see him back there.
Psychotherapists have long sighed and agreed that to get one hospital patient well, "you'd have to change the whole system. There are structural reasons in the very nature of what a hospital is, which will keep patients as they are. Therapists are likely to miss this fact and see only that all the individual staff members themselves need therapy. But, successful therapy for this one difficult nurse will only lead to her going to a better [Page 71] job while the hospital remains the same.
Let us restructure the very idea of "hospital," and set up instead some small community centers in which disturbed people can stay. There nurses will no longer relate never to patients and only to other nurses, there will only be one nurse. Perhaps there won't even be a role such as "nurse. Perhaps there isn't a "psychologist" role at all, but some community people trained to help the patient with the whole situation he is up against—someone trained in the "subprocesses" of psychotherapy.
But if there is no one like that, if there is only the small clinic instead of the large hospital, only the "out to the community" shove instead of the "they must stay in forever" attitude, if there are only social clubs and job-training, it won't work either! Group therapy contributes a major "subprocess" I haven't yet mentioned, largely because here the subprocesses are best known.
I want to mention it as an example of how one can draw certain essentials from psychotherapy and train people in that, without committing them to the long term responsibilities, exclusiveness, psychological focus, and small numbers which therapy involves. From group therapy have come T groups, marathon groups, encounter groups, sensitivity groups, brainstorming groups. It is now well known that one need not exclusively delve into intrapsychic personality troubles in order to get the advantages of this sort of group process.
For example, a group of advertising men spending a day to brainstorm ideas for an ad, respond to each other acceptantly any idea, no matter how it may sound at first, is gone into. In a so-called "sensitivity" group self-awareness is learned from the ongoing interaction, not from what people say about themselves.