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Psychotherapy With More Disturbed Patients: Strategies for the 21st Century

For 34 years, Sheppard Pratt has held an annual event in which both local researchers and established clinicians from around the country present papers on such topics as mood disorders, aggression, family therapy, or borderline disorders. This year's theme, "Psychotherapy with More Disturbed Patients: Strategies for the 21st Century," reflected obvious concern over treatment for the hospitalized ill in an era of short-term stay. The invitees presented work on both psychotherapeutic treatment techniques and the neurobiology of traumatic disorders. Richard Munich, M.D., Medical Director and Chief of Staff at the C.F. Menninger Clinic in Topeka, presented the Harry Stack Sullivan Lecture. He described his work on psychotherapy with psychotic patients. With newer anti-psychotic medications, more patients can be effectively reached by psychotherapy and can live outside the confines of a hospital. Dr. Munich stressed the need to understand the phases of psychotic illness and the treatments specific for each phase. In the acute phase, the patient's active psychotic symptoms, impairment of judgement, and social withdrawal need to be addressed through medication and active psychosocial interventions. The convalescent phase requires attention to the therapeutic alliance, as well as education about illness and the problem of medication compliance. Social rehabilitation is important to address at this phase. During the stable or plateau phase, the psychotic patient is often more amenable to supportive or expressive psychodynamic psychotherapy. A different therapeutic vantage point was presented by Vassilis Koliatsos, M.D., Director of the Sheppard Pratt Neuropsychiatry Clinic and a faculty member at Johns Hopkins University Medical School. Dr. Koliatsos discussed how neurobiologic factors may affect patients who have suffered disorders of trauma or neglect. Recent studies have demonstrated loss of volume in the hippocampus by 8 to 10% in patients with post traumatic stress disorder. There is evidence that this is mediated by excessive endogenous steroid exposure in the brain. The hippocampus is the area of the brain responsible for the transfer of short-term memory into long- term memory. It allows for memories to become independent of the specific context in which they are first encoded and provides the mind with a great deal of mental flexibility in working with memories. When the hippocampus is disturbed, specific memory problems are encountered, such as we see in Vietnam veterans and victims of child abuse. Dr. Koliatsos also described another set of studies in which the effect of maternal neglect was studied in rats. When rat pups are neglected by their mothers, specific neuronal deficits occur. These rats grow up to be prone to symptoms similar to human syndromes of chronic anxiety and depression. Yet it is clear, Dr. Koliatsos reported, that there is constant remodeling of neuronal synaptic structure throughout life, and that such remodeling is responsive to lived experience and treatment efforts as well. Several commentaries on the management of borderline and narcissistic personality disorders were presented at the day-long symposium. Alicia Guttman, M.D., a psychoanalyst and faculty member at the University of Maryland School of Medicine and Sheppard Pratt, discussed the problem of pathological narcissism in a paper she coauthored with Donald Ross, M.D., Director of the Division of Education and Residency Training at Sheppard Pratt and Associate Professor of Psychiatry at the University of Maryland School of Medicine. Two cases highlighting the problem of narcissistic rage and envy were presented. Dr. Guttman described the importance of empathy in dealing with narcissistic injury, using the confrontational techniques of Otto Kernberg together with the empathic immersion of Heinz Kohut. Dr. Guttman emphasized the importance of technical flexibility and steadfastness in the face of the patient's anger and tendency to distance himself from the therapist; the latter must squarely face the patient's destructive envy and fear of attachment. She also described techniques of using counter-transference to relate to the patient's pain. Martha Stark, M.D., a Lecturer in Psychiatry at Harvard Medical School and faculty member at Massachusetts Mental Health Center, discussed her outpatient psychotherapeutic work with borderline personality disorder patients. These patients experience great difficulties managing anger, and are impulsively prone to harm others or themselves when disappointed. Dr. Stark discussed the use of containing statements to help patients stay safe and remain in therapy. A containing statement has two parts: the first expresses an empathic understanding of the patient's pain, while the second enforces limits and states reality. Containing statements bring the patient's observing ego into alignment with the therapist and helps the patient develop an internal locus of control. For example, when the patient is not leaving at the end of the hour, Dr. Stark suggests stating "You wish you could stay, but as we both know, our time is up and we need to stop." This acknowledges the patient's wishes and the fact that the therapist is aware of them, while at the same time setting a limit. With the chronically suicidal patient who learns that the therapist will be away, Dr. Stark suggests a comment such as "You are filled with anger and disappointment that I cannot be here when you need me, and you feel like hurting yourself to stop the pain and get back at me. But we both know that if you are ever to get better, you are going to have to find a way to talk about this and not take another overdose of your medication." Both patient and therapist must find ways to survive the destructive behaviors which occur in therapy. And it is the therapist's consistent capacity to help the patient contain overwhelming negative affects that ultimately leads to a meaningful therapeutic relationship. Salvador Guinjoan, M.D., a third year psychiatric resident at Sheppard Pratt and winner of the Clarence G. Schulz Prize for the best resident paper on a clinical topic, presented his work on the use of metaphor in psychotherapy with more disturbed patients. He pointed out how many of the patients we now see in an outpatient setting are "ambulatory inpatients." They are still quite disturbed, but do not have the holding environment of the hospital to directly assist them. Consequently, they are prone to leave therapy if the therapist is too direct in his or her interpretations, or not active enough. The therapist must learn new ways of managing the patient's anxiety. One way of dealing with this is to recognize the patient's use of metaphor to express himself, and even to distance himself from central conflict areas. For example, Dr. Guinjoan described a psychotic patient from a very controlling family who frequently manipulated the truth. The patient deeply resented this, but could not talk about it directly. Indeed, when the subject was broached, he could become more thought disordered and delusional. However, he was a student of history, and began to talk in therapy about how early colonial powers dominated residents by changing the meaning of the laws so that any resistance to occupation was illegal or wrong. Dr. Guinjoan was able to work on the issues of dependency, separation, and individuation by discussing the history of the French influence in Algeria and thus succeeded in dealing with conflict without precipitating a decompensation. Miles Quaytman, M.D., a Senior Psychiatrist at Sheppard Pratt and Medical Director of the Weinberg Quarterway House, presented his work on the holding environment. Dr. Quaytman's work was highlighted in the last issue of Sheppard Pratt's Psychiatric Review. He has compared inpatient treatment of a borderline personality disorder 10 years ago with today's emphasis on partial care in association with short-term hospital stays for acute decompensations. Dr. Quaytman also described the importance of a sophisticated team approach in the management of borderline states. Donald Ross, M.D. Dr. Ross is Director of Residency Training at Sheppard and Enoch Pratt Hospital


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