This morning, I entered my office at the community mental health center in Baltimore city where I have practiced for six years. I was greeted by 12 voice mails, four marked “urgent” by the caller. I returned the calls in between sessions with seven patients; all have major mental illnesses with diagnoses ranging from paranoid schizophrenia to major depressive disorder. One of these patients needed to be assessed for safety and possible hospitalization. I also did three telephone intakes, ran a group, provided clinical supervision to other staff, and completed over 20 pages of state-required paperwork. This is a typical day for a therapist at a mental health clinic.
I have an average of one hour to evaluate a new patient, and during that time there are 15 forms that need to be reviewed and signed by the patient, a 49-question survey to be completed for insurance authorization, and a mandated clinic evaluation that covers a lot of information in a limited amount of time. As the minutes tick away, I interview the patient in the midst of these competing demands. There is little incentive to get information on childhood experience and family history, and limited time for the patient to share his or her story in a free-flowing manner. However, because of my own analysis, as well as working with an analytically trained supervisor, I became convinced that understanding defenses and the dynamics driving behavior are key components of the therapeutic process. As I went on to complete further psychotherapy training at an analytic institute, I found that working in-depth was not only possible with the chronically mentally ill, but that it made the work more meaningful for the patients, and for me.
There are challenges to being a psychodynamic therapist at a mental health clinic. It can be difficult to maintain the framework for treatment in what can be a chaotic environment. I cannot predict when the overhead pager will ring out with my name or when another patient's crisis will prevent a timely start to a session. However, my thinking about those interruptions as important opportunities to understand something about the patient infuses the work with a richness that it would not have otherwise.
…working in-depth was not only possible with the chronically mentally ill, but that it made the work more meaningful for the patients, and for me.
A vast majority of the patient population at the clinic is diagnosed with a psychotic disorder. There is a strong emphasis on biology with medication often being the first step in treatment. I have seen patients make dramatic turnarounds with the right medication for their conditions. Often, the thinking stops there. Measurable improvements can be seen in the daily functioning of the individual and treatment goals are considered obtained. However, it is often after the right medication has been administered that deepening the work becomes possible. For patients who have enough ego strength, time in therapy can then be devoted to issues of personality and character, leading to even greater improvement and more meaningful relationships.
In this setting, I have been able to incorporate a psychodynamic understanding of my patients' illnesses to provide analytically informed treatment. This is illustrated in the case of Sherry, a 65-year-old Caucasian woman who receives services at the clinic. While she is unique in many ways, she is a typical patient of this setting, once describing herself by saying, “I'm single, uneducated, unemployed, and living off the state.” Sherry has a chaotic life, paired with few external resources. Struggling for years with bipolar I disorder with psychotic features, Sherry struggles in her treatment with a tendency to act impulsively. Her treatment is riddled with lateness, noncompliance with medication, and inconsistency with attendance.
Lauren Scott Janssen, M.S.W., is a graduate of the Adult Psychotherapy Training Program at the Baltimore Washington Center for Psychoanalysis. She is coordinator of Special Services at the Harford-Belair Community Mental Health Center and has a private practice in Baltimore.
In his 1995 paper, “Do Actions Speak Louder Than Words? A Query into an Enigma in Analytic Theory and Technique,” Fred Busch notes that, as clinicians, many of us have “mistakenly judged actions as entirely antagonistic to the psychoanalytic process. This is most succinctly captured in the pejorative term ‘acting out.’” Busch further reminds us that “thought is under the domination of action for a much longer period of time than has generally been recognized… Piaget believes it is not until a child is around age seven that one can talk of his having a relatively integrated cognitive system with which he can organize the world relatively free from action referents.” Thus, instead of lapsing into thinking of action as interference to treatment, there is a reminder that actions in treatment often represent regressions to preverbal stages of development. With this in mind, I approached Sherry's action as an important part of our work and tried to incorporate it into the treatment as a tool to help us learn more about her internal world.
Sherry did not shy away from telling me that she did not plan to take medication forever. Although she was prescribed antipsychotic medication to address paranoia, she would stop taking it at times and then quickly decompensate. While I can remind Sherry of this pattern, she still clings to the fantasy that, “if I can get my life in a better place, I won't need it [psychiatric medication] anymore.” Due to the potentially severe nature of psychotic illness, it is very tempting to take a dictatorial approach with patients regarding medication compliance. However, by not taking a superego, authoritarian position insisting she take medication and instead approaching it from a neutral, curious standpoint, I worked with Sherry to understand the shame, stigma, and fear that emerged as we discussed what taking medication meant to her. This allowed us to dig deeper into her delusional thinking regarding medication, a process that would not have taken place otherwise.
Sherry also had a pattern of noncompliance with appointments. The following excerpt is from a session that took place after three missed visits. Sherry arrived 15 minutes late. She said, “I'm here because I said I was going to be here.”
I noted, “You're here, but you seem hesitant.”
Sherry responded, “Yeah, I mean, what's the point? Everything's all messed up. And what are you going to do about it? I got a bill from the doctor's office. They called and said, ‘If you don't keep your appointments, I can't help you or treat you effectively.’ Well then, don't treat me. I don't care.”
I replied, “You're talking about your doctor, but I wonder if any of what you are saying reminds you of coming here?”
Sherry said, “I have to come back here. You're the only person I can trust. Isn't that messed up? You're the only person I can trust, and I don't even know you.”
By suggesting to Sherry that perhaps the feelings she was experiencing about her doctor applied to me as well, we are able to reach the heart of the matter, Sherry's conflicted feelings about being close with me. While many paranoid patients have difficulty with trust, my appreciation of the importance of the transference as the therapeutic vessel allowed us access to feelings that would otherwise have remained obstructed.
So, while Sherry is not the typical candidate for an analytically informed psychotherapy, the utility of such an approach is clear in her treatment. Uncovering and identifying underlying psychodynamics help clarify what is motivating her so that she can have a choice about whether, or how, to act. Sherry's case clearly demonstrates the broad-reaching impact of creative use of psychodynamic techniques. The clinic setting along with the psychotic presentation could have been considered a barrier to this type of work. Instead, by meeting Sherry where she was, I was able to use my understanding of these principles and techniques to enrich the work, and her life as well.