The use of the psychodynamic life narrative in crisis supervision.

The psychodynamic life narrative is a statement that is made to the patient that gives current emotional reaction meaning in the context of his life history, and shows it to be a logical and inevitable product of previous life experiences. Because the patient in crisis characteristically present feeling overwhelmed, confused and needy, there is a sense of urgency and helplessness which impacts on the resident therapist's intervention. Common countertransference reactions which can result are assuming omnipotent control, a grandiose rescue fantasy or passivity. The authors present a clinical vignette to illustrate the supervisory process and its vicissitudes in the use of the psychodynamic life narrative in supervision of crisis work. The early identification of the "rescuing" response led to the rapid formulation of the psychodynamic life narrative and a successful outcome.

Boundary transgressions in the psychotherapeutic framework: who is the injured party?

The authors emphasize the therapeutic value of establishing and maintaining boundaries between clinician and patient. No universal definition of a therapeutic boundary exists, and this ambiguous term spans a diverse spectrum from benign crossings to harmful violations. Understanding of the traumatic nature of faulty boundaries in psychotherapy has derived largely from the study of severe sexual transgressions by therapists. In contrast, this paper highlights the importance of recognizing a wider and more subtle variety of boundary crossings, especially those by patients, which can compromise the integrity of treatment and traumatize the vulnerable therapist. This is exemplified here in the case study of an incest survivor and a novice clinician.

Sixth cranial nerve palsy--unusual presenting symptom of lithium toxicity?

This paper discusses a case of neurotoxicity which developed in the course of treatment of bipolar affective disorder with Lithium. It deals with the issues of Lithium levels, concomitant usage of Phenothiazine and addresses the important question of toxicity occurring at normal serum Lithium levels.

The characterologically difficult patient: a hospital treatment model.

A treatment model for the hospitalized borderline patient has evolved from the long-term, intensive treatment of these patients in a psychodynamically oriented setting. Four stages are identified and described. Each has a therapeutic goal and strategy, and repeatedly observable patient responses and staff counter-responses. Although patients vary in the lengths of time in each stage and there is much back and forth between stages, the regularity with which this pattern occurs greatly increases the capacity of the treating personnel to understand and guide the treatment process. The model clarifies perplexing, discouraging, or stale-mating affects and behaviours in the patients, and misleading counter-therapeutic affects and behaviours in the staff. Further, it can predict certain features and, to some extent, probable outcome in any particular course of treatment.

Psychotherapy and the inpatient unit: a unique learning experience.

This paper describes the advantages of an inpatient setting for the teaching and learning of psychotherapy. Contributions to this process derive from the continuous and intense expressions of conscious and unconscious dynamics, transferences, and object relationships by the patients, the obligation on residents to therapeutically engage in a relatively exposed way with all the patients under their care, the availability and familiarity of the staff supervisors who participate in assessments and decisions regarding patient management and psychotherapy, and the collaborative work of all the other team members. Conditions of the setting which make this possible are the strong psychodynamic orientation of all the staff, the resident's role as manager and psychotherapist, the staff psychiatrist's role as supervisor and team leader, and the completely open communication among all the treating personnel.

Therapeutic milieu: a dynamic approach.

This paper deals with the establishment of a therapeutic milieu in an acute care general hospital setting. The rationale and structure are defined, and dynamic considerations are elaborated. Conclusions are drawn from our experience suggesting that the therapeutic milieu is a viable and a more effective treatment delivery system than that provided by conventional inpatient units.