Helplessness in the helpers

Psychosocial and Psychodynamic Considerations Informing Factitious Disorder

Factitious disorder is a condition in which patients deceitfully present themselves as injured or ill in the absence of obvious external reward. It is difficult to diagnose and treat, and little rigorous evidence exists in the literature. While larger studies have revealed some clinical and sociodemographic patterns, there is a lack of consensus on psychosocial factors and mechanisms contributing to factitious disorder. This in turn has led to conflicting recommendations on management. In this article, we review major psychopathological theories of factitious disorder, including the role of early trauma and subsequent development of interpersonal dysfunction, as well as maladaptive gratification obtained from assuming the sick role. Common themes of interpersonal disruptions in this patient population include a pathologic need for attention and care, as well as aggression and desire for dominance. In addition to psychodynamic and psychosocial etiologic models of factitious disorder, we also review associated treatment approaches. Finally, we offer clinical implications, including countertransference considerations, as well as directions for future research.

Prevention of burn-out

There is a widespread concern that the medical profession is itself sick. This is represented in professional disillusionment and demoralisation, an increasing inclination to consider leaving the profession, and the ill-health of its practitioners in terms of their mental health, marriages and use of drugs and alcohol (British Medical Association, 1992). These trends have been attributed, at least in part, to protracted job stress and dissatisfaction, which may in turn be a major determinant in the quality of health care (Caplan, 1994). Although these issues have been cautiously acknowledged for some time, the concept of ‘burn-out’ has provided an opportunity for more open acceptance and creative debate.

The useless therapist: music therapy and dramatherapy with traumatised children

Purpose

– The purpose of this paper is to discuss the use of music therapy and dramatherapy with traumatised children in a residential school through examining the therapists’ experience of feeling useless.

Design/methodology/approach

– Using clinical examples, the paper explores the therapists’ feelings of uselessness and how this experience informs and enables the progression of the work.

Findings

– The paper suggests that feelings of uselessness are a necessary and useful part of the clinical process when working with traumatised children.

Originality/value

– This paper offers an insight into application of music therapy and dramatherapy in this environment, and also into the therapists experience of working with highly traumatised children.

HELPLESSNESS AND THE ANALYST'S WAR AGAINST FEELING IT

In our view helplessness is a primal, often intolerable feeling. It underlies and intensifies other feelings that are also hard to bear. Both analyst and patients face helplessness, and both resort to defenses, often intensely, in order to avoid it. The intensity of this battle can merit calling it a war. The analyst's war is conducted using distancing, anger, blaming and disparaging as well as by intellectualizing the patient's struggles. Patients then find themselves abandoned and helplessly alone. We analysts, of course, want not to fall into the trap of war, and we try to free ourselves from waging it. A major way we accomplish this is through continuously working, often with the help of analysis and self-analysis, to increase our capacity to maintain our emotional stability in the face of these intensities. We learn to find new forms of awareness, beyond words and ideas. It requires a new understanding of what is threatening to us, which fosters a deeper capacity to empathize with the patient. This helps us to find the psychic, physical and emotional space within ourselves in which to hold our helplessness and other profound affective experiences. In this way we become an increasingly steady resource for our patients as well as for ourselves.

Emile, or on devastation: when virtual boundlessness meets inner emptiness

The author's starting point is a psychoanalysis conducted with Emile, a teenager who was unable to form close relationships and was living in a virtual world, planning a school massacre. For him, virtual reality functioned as a bottomless container in which he was no longer a victim of bullying but rather a god. When the boundlessness of cyberspace encounters a "black hole" in the psyche, any fantasies can be put into virtual realization and actions. By recounting his wickedness, violence, destructiveness, and perversion, Emile could start restoring his self boundaries and create his own autobiographical narrative. Unable to sustain the pain of mourning his envelope of invulnerability and omnipotence, however, he prematurely terminated analysis.

Working with despair: a phenomenological investigation

OBJECTIVES

Psychotherapy as an appropriate treatment for clients in despair is an important area of inquiry, particularly given its problematic nature in the therapy and the resulting impact on the therapeutic relationship. This study aimed to explore how psychotherapists experience working with a client in despair through a phenomenological investigation.

DESIGN

A phenomenological epistemology and methodology was adopted as the study was focused on understanding the phenomenon in terms of the participant's meanings of the lived situation.

METHOD

In-depth, semi-structured interviews were conducted with eight accredited psychotherapists who had worked with clients in despair. The interviews were transcribed and analysed using the method of Empirical Phenomenological Analysis (EPA).

RESULTS

Four main themes emerged from the analysis: Psychotherapist's experience of client's despair, Evocation in the psychotherapist, Therapeutic ways of responding, and Supporting the psychotherapist.

CONCLUSIONS

The phenomenological findings inform and support the idea of a client's despair as something that challenges the psychotherapist personally and professionally. With implications for practice, the findings also suggest that in order to prevent the despair from encompassing the psychotherapist, they must locate a therapeutic balance; one that allows them to be with the client's despair, whilst allowing a certain degree of distance from the despair which may enable the psychotherapist to consider hope and to see the client's situation from different perspectives.

Chemistry and containing: the analyst's use of unavoidable failures

Certain patients overwhelm the analyst's capacity to contain both the patient and the analyst's own unbearable feelings. Though some such failures of containing may lead fairly quickly to self-correction and others to clinical impasse, our focus is on an in-between state in which the analyst's ability to tolerate his inevitable failures and gradually to (re)establish his containing capacities through difficult self-analytic work can lead to significant change that might not otherwise be possible. The authors argue that this internal psychological work on the analyst's part, which may require considerable time, effort, and suffering, is an important aspect of "good enough" containing. The unique chemistry generated between patient and analyst plays an important role in both establishing and maintaining this kind of productive analytic process.

Disclosure of a diagnosis of borderline personality disorder

OBJECTIVE

Borderline personality disorder (BPD) is a common psychiatric disorder with a prevalence of 1%-2% in the general population. BPD also has the potential to cause significant distress in the lives of patients with BPD and their families. The diagnosis of BPD, however, is often withheld from patients. The purpose of this article is to explore the history of diagnostic disclosure in medicine and psychiatry and then discuss reasons why clinicians may or may not disclose the diagnosis of BPD.

METHODS

The authors review medical literature about diagnostic disclosure and other issues that may affect the decision to disclose a diagnosis of BPD.

RESULTS

The authors discuss the historical precedents for diagnostic disclosure and reasons a clinician may not disclose the diagnosis of BPD to a patient: questions regarding the validity of BPD as a diagnosis, worries about the stigma of the diagnosis being harmful to the patient, and transference/countertransference issues common in the treatment of patients with BPD. The authors cite factors promoting disclosure, such as the ideal of patient autonomy, possibilities for psychoeducation and collaboration with the patient toward more specific and effective therapies, and the increasing availability of diagnostic information available to patients from sources other than their clinicians.

CONCLUSIONS

There are compelling reasons to make the diagnosis the subject of open examination and discussion between clinician and patient, and reasons to believe that disclosure would serve to advance the patient in his or her recovery.

The suffering of the healer

TOPIC

The severe distress sometimes experienced by nurses in their role as healer.

PURPOSE

To identify the sources that give rise to the suffering of the healer, describe the responses of healers to their sufferings, and make recommendations on how to prepare nurses to cope with suffering.

SOURCES

The concept of the suffering of the healer is derived from the work of Erik Cassell; the framework for understanding responses to suffering from the work of Dorothy Solle.

CONCLUSION

Nurses need to be aware that practice in health care can give rise to the suffering of the healer. Nursing education and administration need to help nurses learn to cope.

Ethics and teaching the art of emergency medicine

This article discusses the art of medicine as it relates to effective teaching. Valuable contributions to such teaching are made through applying ethical considerations to situations unique to emergency medicine. The author includes several appendices for further information on this vital topic.

Dealing with the difficult patient

Dealing with difficult patients can represent a significant burden in the life of doctors. It is more productive, however, to view this burden as a product of the interaction between doctor and patient, for which both have a responsibility, rather than attributing any problems encountered to shortcomings of the patient alone. There is a significant risk in such situations of potentially harmful over-medicalisation. It behoves doctors, therefore, to try to prevent such problems becoming established, or make some attempt to rectify matters if they have already become so. Much is known about the factors that contribute to successful and unsuccessful clinical transactions. The awareness of what doctors bring both as professionals and as individual people to this interaction, will count as much as the practical clinical efforts made towards helping patients.

Using role-plays to teach palliative medicine

Teaching of communication skills in Palliative Medicine can be achieved using a three hour exercise involving role-plays, a time of feedback and discussion, a teaching video and a reading list. Using this teaching method self-ratings of perceived skills recorded on a questionnaire before and four weeks after the exercises showed a significant increase in both undergraduates and postgraduates. The validity of these self-ratings as a tool to measure communication skills was assessed by correlating the self-ratings with the ratings given by the participant and the observers after the clinical scenarios from the questionnaire were simulated in role-plays.

Autognosis rounds for medical house staff

The authors describe the autognosis countertransference rounds for medical house staff at the Massachusetts General Hospital. At these rounds, which have been held weekly for more than a decade in the intensive care unit, countertransference phenomena and their relationship to medical practice are discussed. Methods that have facilitated the autognostic process are provided and highlighted by brief case examples. Participants at these rounds report that their self-awareness increases and the clinical care they provide often improves.

Countertransference in Trauma Work in South Africa: For Better or Worse

Working with victims of political violence evokes strong countertransference reactions in mental health workers. Professionals and lay counsellors alike comment on the intensely demanding, stressful and sometimes invigorating nature of this work. Despite these acknowledgements, however, there is a dearth of literature on the countertransference experiences of therapists engaged in trauma work. This gap is especially pronounced in the available literature on trauma work in South Africa. In this paper the author considers some of the reasons for this omission and then presents the results of interviews with 20 therapists engaged in work with individuals traumatized by political violence (i.e. former detainees and refugees from vigilante violence). Specific countertransference themes are identified and discussed.

Long-term psychiatric treatment

Is long term psychiatric care superfluous? Can it be provided by non medical therapists? This paper examines this question from the perspective of one patient who was in therapy for 20 years.

Physical illness in chronic psychiatric patients from a community psychiatric unit. The implications for daily practice

The prevalence and significance of physical diseases, and health-care-seeking behaviour, were examined in a sample of 218 chronic psychiatric patients from an urban community psychiatric unit. Only 14% declined medical screening. Of the respondents, 53% had one or more probable or certain physical diseases warranting further medical attention. The majority of the diseases found were minor and typical of primary care problems. A severe (i.e. life-threatening) disease was present in 7% of respondents. Of the patients, 87% visited their GP at least once a year. The implications are that frequent consultation with primary care specialists and health-care-seeking behaviour should be noted, and included in any evaluation of the medical needs of chronic patients in community psychiatric care.

Physically ill and mentally ill

Undetected physical illnesses in psychiatric patients are common. Why do so many physical illnesses go undetected? These disorders are difficult to detect and need an elaborate consultatory process. Some of the problems may be related to the fact that psychiatrists do not do physical examinations. Clues suggesting an organic etiology may be attributed to psychodynamic issues by many physicians. In this paper, seven case reports are presented to illustrate the following: perform your own physical examination; do not attribute physical signs to dynamic issues; all physical signs should be explained; be alert to atypical presentations; conduct relevant laboratory workup; avoid bias against unattractive patients; and pose specific questions to consultants.

Psychotherapy of the characterologically difficult patient

The increasing number of characterologically difficult patients in psychiatric practices has produced a plethora of theoretical formulations, treatment strategies and techniques. The major shifts in theoretical emphasis from drive theory to object relations theories and self-psychology has encouraged many psychiatrists to treat these patients in psychotherapy. The heterogeneity and variability of clinical profiles represented in this group of patients, however, still prevents prescription of "the" treatment of choice for this patient population. A major focus on treatment considerations in this paper is the assessment process with emphasis on determining the capacities for inter-personal relationships, psychological mindedness, empathy and psychological soothing of self and others. The advisability of establishing a "contract" as a prerequisite to treatment is suggested as an important factor in determining outcome. Other particular treatment issues are addressed such as frequency of sessions, "secrets", premature provocation of intense affect, medications, consultations, hospitalization, self-mutilation, substance abuse and indications for termination. The complex vissicitudes of the transference and countertransference processes with this group of patients is pointed out especially those feelings of helplessness and range sometimes experienced in the counter-transference. Long term intensive psychotherapy with many of these patients probably still belongs to the area of therapeutic heroics. Hard evidence for good and poor outcome is scarce and therapeutic zeal is too often based on anecdotal testimonial from adherents of one approach or another.

The fantasy residue: an antitherapeutic force on the psychiatric inpatient service

This paper will attempt a model of organizational behavior to the study of the origin, perpetuation, and rectification of certain antitherapeutic forces (Sacks and Carpenter 1974) on inpatient services, which I shall call the ward's "fantasy residue." The fantasy residue consists of the enduring antitherapeutic patterns of dealing with patients that have become normative for a given ward and evolve from irrational staff responses to a variety of stresses in the absence of appropriate corrective administrative actions. Because they originate in irrational responses to complicated situations of patient management or staff relations, these forces can be called "fantastical." Because they tend to flourish and remain active long after the specific conditions which gave rise to them changed or cease to exist, they are "residual." Hence, the name "fantasy residue." Once established, the fantasy residue can persist either as unacknowledged maladaptive responses in the ward's milieu or as openly espoused, presumedly valid "methods of treatment." In either case, the ward staff an its leaders lose sight of both the irrational base and antitherapeutic consequences of these attitudes and actions. In this sense, a ward's fantasy residue is analogous to a person's ego syntonic character resistances and correction requires a process of confrontation, recognition, and facilitation of objective self-scrutiny among staff and patients.

Evaluation and care of suicidal behavior in emergency settings

The author offers a sequential protocol for the evaluation and care of suicidal behavior in emergency settings. This protocol contains the following components: 1) a review of the limitations of clinical and demographic risk factors; 2) an exploration of frequent negative reactions that arise during the suicidal encounter in clinicians; 3) an objective schema for grading suicidal behavior; 4) an understanding of chronic suicidal behavior; and 5) a flexible treatment approach. Pertinent literature on suicide evaluation and management is reviewed with an emphasis toward the clinical applicability in emergency settings.

The borderline patient in the general hospital

The usefulness of the general hospital inpatient service for the borderline patient is described. The short-term nature of most general hospital units requires a setting that facilitates the rapid establishment of a holding environment and the re-establishment of self-object transferences. Borderline patients have particular difficulty in accepting responsibility for their feelings and behavior and, instead, tend to blame themselves and others. An approach to inpatient care that defines expectations of both patient and family prior to and early in the admission of the patient is elaborated clinically and theoretically. Such an approach offers a way of working with the potential regression in borderline patients, especially around the important issues of responsibility and blaming. The staff's awareness of countertransference problems related to the patient and family as well as to the patient's therapist are described as important ingredients in successful work with these patients.

Taking care of the hateful patient

"Hateful patients" are not those with whom the physician has an occasional personality clash. As defined here they are those whom most physicians dread. The insatiable dependence of "hateful patients" leads to behaviors that group them into four stereotypes: dependent clingers, entitled demanders, manipulative help-rejecters and self-destructive deniers. The physician' negative reactions constitute important clinical data that should facilitate better understanding and more appropriate psychological management for each. Clingers evoke aversion; their care requires limits on expectations for an intense doctor-patient relationship. Demanders evoke a wish to counterattack; such patients need to have their feelings of total entitlement rechanneled into a partnership that acknowledges their entitlement--not to unrealistic demands but to good medical care. Help-rejecters evoke depression; "sharing" their pessimism diminishes their notion that losing the symptom implies losing the doctor. Self-destructive deniers evoke feeling of malice; their management requires the physician to lower Faustian expectations of delivering perfect care.

Treating the untreatables: identifying the somaticizing borderline patient

Both medical and psychiatric services have long been challenged by patients with either clear psychosomatic disease or disease complicated by functional elements. Not only are these patients unresponsive to the usual medical management, but they seem to derive little benefit from the usual psychotherapeutic approach. This paper is intended as an examination of this group of difficult patients for the purpose of: 1. creating a suggestive profile to aid in the identification of such patients; 2. anticipating some of the difficulties experienced by clinicians and institutions responsible for their care; and 3. formulating a framework for understanding the basic difficulty experienced by some of these patients as an expression of borderline personality phenomena.