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Psychotherapy Assessment, Supervision and Formulation (Assessment
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Psychotherapy Assessment, Supervision and Formulation
What is Therapy
- Emotionally charged atmosphere
- Meeting of helper and help seeker
- Symbolism & institutional transference
- Myth Needs to be adressed what the clinician and the patient see as the reason for refereal
- Ritual
- Shared communications
Different Modalities
- CBT
- Family therapy
- Group therapy
- Individual dynamic work
- Couple therapy
- Psychosexual therapy
- CBT-groups
- CAT-groups
- Mentalisation
Specific elements - of specific therapies
- Theoretical details
- Rules of delivery and rules of supervision
- Rules of monitoring
- Manualised interventions
- Specific techniques and forms of intervention timed to the patient’s responses or at a timely moment
- Specific conditions or diagnoses
- Training and standards of practice
Non specific elements:
- A theory
- Empathy
- Overcoming conflict and discontinuities
- Therapeutic alliance
Assessment
- Background
- Referrals for.... referral narrative
- Patient’s narrative
- Assessment process
- Diagnosis or problem formulation
- Proposed interventions
- Explanation but anticipating resistance, and sustaining confidence and optimism
- Honesty around expectations
Elements of Assessment
- Immediate concerns
- Narratives-patient, referrer, family
- Facts-opinion-informed speculationjudgement
- Personal history, developmental history
- Family psychiatric history
- Drugs/alcohol use
- Patterns of relationships
- Mental state-awareness-insight
- Formulation
Core Concepts
- Object relations
- Transference
- Countertransference
HinshelwoodOne of the tasks for the assessor:
- identify the core object relations
- infantile object relations
- the current life situation
- transference
- therapist, and referrer? consider entanglements in previous treatments and referrals, crises
Dynamic Process
- Transference
- Feelings from early object relations that enter a current relationship unconsciously
- Countertransference
- Feelings the therapist develops in response to patients transference and projected object relations
Assessment itself
- Read referrals: for what and why? – also think about risk
- Early development & life course
- Sensitive to details, subtle clues
- Length of relationships: treatment and personal, life events
- Supports and challenges to therapy-experience of therapy-reveals ORs
Parallel Processes
- History, mental state, diagnosis and formulation of problem
- However, also consider emotional tone, transference and countertransference
- Ease of communication
- Defences and resistance of patient
- Motivations for change
- Enters your relationship-that with others that with supervisor
Ease but thoughtful precision
- Let patient talk, tell their story
- What comes first for them, as they talk
- Who are their friends, what sorts of relationships to they have
- How trusting are they
- Are there repeated patterns of relations or
OR
- How aware are they of tensions in their relationships-can they own the problems
- Are they curious
Look for patterns of relationships
- These suggest internal objects
- Object relations & reciprocal roles
- Within personal history (family, work colleagues, partners, children, sibs etc), in reports of experience with services, and these come alive in the consulting room
Consider
- How seriously does patient take their problem (do they want to change)
- Co-morbid drug and alcohol problem
- Strong counter-transference in the room
- Perplexity and confusion in the therapist
- Avoidant/ed, critical/cised, challenging/ed, infantilising/ed, idealising/ed
Transference and Countertransference
- Ambivalence
- Fear
- Are you strong enough
- Avoidance
- Enactments reflecting internalised object relations
Referral
- How long (have the patient been waiting)
- Who refers and why
- Problem history and timing of events
- Coping-successful and failed
- Strengths in coping
- Areas of function and need
- social support, education, family, housing
Formulation
- Referral, arrival to see you
- History & biography, life events
- Developmental paths, and object relations and patterns of relationships
- Use tools like outcome measures (CORE, GAD, PHQ9), psychotherapy file
- Over 1-2 sessions or more
- Trial interpretations/Transference/CT
- Diagnosis
- Psychiatric-ok, important, but not enough
- Developmental or process diagnosis also, about various life stages at which patient appears to have developed particular patterns of behaviour
- Their narrative-your CT and T inform you
Supervision
- Reflections and process information
- Consider alternative formulations and what is and is not visible and known
- Emotional disturbance or anxiety or uncertainty in training but also for experienced therapists
- Challenging, argumentative, frightening, dreamy, waking up, thought provoking
- A new language and careful use of concepts and theory
- Consonance between theories and concepts
- Modelling and learning from experience
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