Mental Health Consultation

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1. INITIAL ASSESSMENT

Believe me, every heart has its secret sorrows, which the world knows not; and oftentimes we call a man cold when he is only sad.

Henry Wadsworth Longfellow (1807-1882)

ost psychodynamic psychotherapy cases stumble, come to an impasse, or fail because the patient’s suitability and mo-

tivation for treatment had not been properly evaluated. Indeed, some psychotherapists take pride in starting a case ‘cold’ i.e. with- out a formal assessment of patients’ psychopathology, ego-capaci- ties, and psychological-mindedness. This approach, popular with some ‘classical’ psychoanalysts and those who naively imitate them, often leads to unpleasant surprises. Even in the absence of major fiascos, the lack of agreement between the patient and thera- pist about the modality and aims of treatment can contribute to fu- ture difficulties.

It therefore seems preferable to conduct a proper assessment be- fore deciding upon the start of psychotherapy. This period, starting from the very first moment of contact between the patient and therapist usually spans over one to three sessions, preferably con- ducted on consecutive days.1 It provides an opportunity for the as- sessment of the nature and severity of the patient’s psychopatholo- gy. It also gives the two parties a chance to get an emotional ‘feel’ for each other. Through direct questioning, encouragement to elab- orate on what has hitherto remained emotionally abbreviated, and patiently listening in a non-judgmental way, the therapist gathers

Akhtar, Salman. Turning Points in Dynamic Psychotherapy : Initial Assessment, Boundaries, Money, Disruptions and Suicidal Crises, Taylor & Francis Group, 2009. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=689958. Created from ashford-ebooks on 2021-11-03 02:19:54.

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important information about the patient. Through expressing his distress, following the clarifying leads of the therapist’s interjec- tions, and listening to his own self, the patient begins to feel more organized. Experiencing a dignified sense of human affinity and feeling ‘held’ (Winnicott, 1960) in an informed setting, the patient senses an opportunity for betterment and psychic growth.

These developments, while happening silently, are both the re- sult of a proper initial evaluation and the facilitators of it. Their end-point is the mutual agreement between the two parties to un- dertake the work of psychodynamic psychotherapy with a well- laid out framework and clearly understood plans. However, before arriving at such closure, a number of steps have to be traversed. Some of these steps are concrete and formal, others nearly imper- ceptible.

RESPONDING TO THE FIRST PHONE CALL

The first contact between the therapist and a prospective patient often occurs via telephone. Many things can be learned and many trends can be discerned during this contact. Careful attention should therefore be paid to what the patient says at this time. Both the form and the content of his or her message should be noted. One might find that the patient is cryptic and reluctant to give in- formation. Or, one might note that the patient is talkative and has difficulty restraining himself. To be sure, no definite conclusion can be drawn from these bits and pieces of information but one should tuck them into the back of one’s mind and use them as background or as topics of specific investigation once the patient arrives for the first interview. The following clinical encounter illustrates this point.2

CLINICAL VIGNETTE 1 While setting up an appointment via telephone, John Schmidt asked me twice whether my office building had a name, such as the Pan Am Building, the Chrysler Building, and so on. I was intrigued by his insistence, since I had already given him the street number of my building. I also noted that both the buildings he mentioned were in New York and not in Philadelphia, where I practice. I politely repeated that

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my building did not have a name, keeping my sense of curiosity for later.

During the evaluation session, the first thing I learned was that his full name was John Schmidt, Jr. Next, I gathered that he had a pattern undermining his achievements, in the realm of both romance and business, just when success was around the corner. Much unconscious guilt seemed to lurk in his psyche. To look for the sources of such guilt, I turned to ex- ploring his childhood development. Now I learned that despite having an older brother, it was he who was named after his father. Upon my inquiring about it, he agreed that this was not customary but said that he had never thought about the reasons for this un- usual situation. Further questioning revealed that his older brother was mildly retarded. At this point, I ventured a hypothesis. Could it be that his older brother had at first been named after their father, only to be given a different name after the discovery of his retardation? The patient was moved by this sugges- tion and, though he did not remember hearing any such thing while growing up, began talking about his sadness about his brother and his guilt over his own success, which he had impressively undermined on many occasions.

As all this came pouring out, I became aware that he had unconsciously given me a clue to his problem by insisting on the phone that my building (me) have a bigger, better name than merely a number. Now I brought up our telephone conversation and pointing out that his insistence upon my building (i.e. I) having a better name was a disguised way of ‘returning’ his borrowed name to his older brother. In essence, it was his way to repair the damage he had felt he had done. The patient began to sob and it was clear that he felt understood in a way that he had never experienced before.

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What this dramatic example demonstrates is that by paying close attention to the patient’s phone call, one can pick up important clues regarding his or her problem. These can be used to clarify and document the hypotheses that one begins to develop during the evaluative sessions.

In addition to this, there are other guidelines to keep in mind while responding to a call by a prospective patient.

It is advisable not to hurry in returning the phone call from a person whose name one does not recognize and who might be a prospective patient. Contrary to ordinary ‘good manners’, it is better that one waits a little (say, from a few hours to even a full day) before answering such a call. An interval of this sort allows one to ‘suddenly recall’ that one actually knows this person (e.g. he may be an ongoing patient’s boyfriend) and should ac- tually not call him or her back. Or, one might receive collateral information (e.g. from another person’s phone call) which af- fects the manner in which one would handle this call.

It is also good to return a phone call from a potential patient when one can spare some 5-10 minutes of peaceful and uninter- rupted time. While lengthy conversation at this point is hardly indicated, having the cushion of a few minutes comes in handy if unexpected complications begin to arise.

Rather than giving a specific time that is convenient for oneself, the therapist should try to involve the patient in choosing the time for the first appointment. Asking such questions as ‘How urgent do you think the situation is?’ or ‘When was it that you were planning to see me?’ permits the patient to negotiate a re- alistically needed and feasible appointment. More importantly, allowing the patient to exercise some control subtly emphasizes the mutuality of the therapeutic undertaking and helps restore the patient’s self-respect at a time of difficulty and self-doubt.

Patients’ questions about fees and billing should be answered in a factual manner. It is inappropriate and misleading to tell a pa- tient to come in saying ‘we will discuss the fee issue when you are here’. This can put the patient, who comes and reveals his

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inner turmoil, in a disadvantage if he can not afford the thera- pist’s fees and has to be referred elsewhere.

Conditions put by the patient for coming or not coming should neither be accepted nor rejected. One should emphasize that both parties need to have open-mindedness about such matters. Neither undue flexibility nor stern rigidity is helpful. What is needed is a firm adherence to the stance of neutrality, curiosity, and respect for the complexity of mental processes.

It is considerate to inform the patient right away of any con- straints from one’s own side. For instance, if one does not have time to take a new patient or one is leaving soon for a long va- cation, the patient should be informed of it. Such forthrightness helps preclude feelings of betrayal and may prevent even more serious complications in highly regressed and needy patients.

One should give clear and specific directions about the location of one’s office and not assume that the patient knows his way around. Often, the patient’s lateness for his first appointment is the result of the vague directions given by the therapist rather than of resistance and enactment.

THE PATIENT’S ARRIVAL FOR THE INITIAL INTERVIEW

The patient’s appearance, behavior, and manner of arrival also can provide significant information even before a formal evaluation has begun. There are many things to be noted here: is the patient appropriately dressed? How is his personal hygiene? Are there any outstanding mannerisms, scars, or tattoos? Does he look angry, sad, happy, nervous? Also, does he come on time? Does he arrive late or, conversely, too early? Or does the patient come at a com- pletely different time than was agreed upon?

CLINICAL VIGNETTE 2 After having waited for Gina Spencer, who had sought a consultation with me, for about twenty min- utes, I received a frantic phone call from her. She was looking for my office in a building five blocks away. Where did I say my office was? When I repeated my

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address, she realized her ‘mistake’ and wanted to know if she could still come over for her appointment. Thinking that not much time would be left by the time she arrived, I offered her an appointment on a subse- quent day. She apologized for her ‘mistake’ and ac- cepted my offer.

On the day before Gina’s second appointment, I came out of my office after the last patient of the day had left to find her sitting in my waiting room. She was enraged and said that she felt very humiliated by my having ‘abused’ her in this fashion! Puzzled, I asked what it was that she felt I had done to her. She responded by saying that I had kept her waiting for an entire hour while seeing another patient. It took her a few minutes to realize that she had come a day earlier than her scheduled appointment!

Now, there were these two enactments even before we began a formal consultation. First, she went to the wrong building and was frantically looking for me. Second, she came at the wrong time and felt ‘abused’ by me. I kept these in mind and decided to see what in our ‘third’ encounter (i.e. our first formal interview) might shed light on the communications contained in these enactments. (Besides, of course, I noted the propensity toward acting out, resistance, sado- masochism, and use of paranoid defenses).

In her subsequent appointment, for which she ar- rived punctually, Gina told me that her main difficulty was constant anger at men, sexual disinterest, and de- pressive mood swings with occasional suicidal thoughts. She revealed that her father, to whom she was very attached, had abruptly left the family when she was five years old. She never saw him afterwards and was always ‘searching’ for him. When she was eight years old, her mother remarried. Her stepfather sexually abused her until she was thirteen years old. At this time, the patient moved out the house and started living with an aunt. As this material came out, I brought to her attention that her frantically ‘search-

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ing’ for me the first time and feeling ‘abused’ by me the second time were perhaps her ways of putting me in the place of her real father and stepfather, respec- tively. Till the time I was in either position, I added, she could not relate to me. Perhaps she needed a third chance, a new experience. The patient began to cry and, after composing herself, revealed more details of her anguished life.

The point I am trying to make here is that enactments as gross as these cannot be ignored. They must be thought about and recog- nized as up for discussion. Vigilance combined with tact is the key here. This applies not only to the patient’s appearance and behav- ior but also to the things that they might bring along with them.

CLINICAL VIGNETTE 3 As Alex Bartlett, a thirty-four year-old lawyer, entered my office for his first interview, I noticed that he was carrying a popular magazine in his hand. Sitting down, he put the magazine on the table near him. The session proceeded along conventional lines while, in a corner of my mind, I kept wondering about the maga- zine. Oblivious to my concern, he went on to describe the interpersonal difficulties that had led to his seek- ing help. He said while finding women was not diffi- cult for him, keeping them involved certainly seemed a problem. One after another, they left him complain- ing of his aloofness and self-sufficiency. I found my- self looking at the magazine he had brought along but decided to wait before saying anything about it.

Moving on to his family background, Alex revealed that his parents had divorced when he was four and, for the following three years, his mother toiled hard to raise him and his two older sisters. She worked long hours and expected the children to be well-behaved. Alex grew up to be a courteous young man who was repeatedly abandoned by women who found him nice but unengaging. He suffered greatly since he wanted involvement and mutuality in his life. At this point, I

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asked him about the magazine. He seemed surprised and said that he had brought it for reading in the waiting room. I asked him if he thought that I would have no reading material there and if he could see how this seemingly innocuous behavior betrayed his anxiety about dependence and attachment. I added that perhaps it was this sort of ‘self-sufficiency’ that was found unacceptable (and unconsciously rejecting) by his girlfriends. He was taken aback but could read- ily see the dynamics in action. His eyes filled up with tears and he said, ‘But I can’t help it. I have always re- lied upon myself.’ Yet there was a clear sense in the of- fice that an aspect of his problematic ‘character armor’ (Reich, 1933) had already been made ego-dystonic.

I can offer many other examples of this sort but will suffice to say that the therapist must note and make use of the messages con- tained in the physical possessions patients bring with them.

There are still other things to observe. For instance, the arrival of an adult patient (who is not psychotic, organically impaired, or a fresh immigrant to the country) in the company of a relative or friend should raise questions in the consultant’s mind. Is there ego impairment here? Paranoia? Separation anxiety? Some phobia? En- actment of some unconscious fantasy? Such behavior could reflect any of these or might imply something completely different. The point is to observe it, consider it data. Similarly, the observation that the patient arrives carrying too many things should be silently registered. It may lead to something or it may not, but it cannot be ignored. Finally, our own very first feelings about the patient should be jotted down in the back of our minds for further private exploration. This might yield useful information about either or both parties in the dyad of a consultation.

ASSESSING THE NEED FOR TREATMENT

Nature And Severity Of Symptoms

The first formal step in initial assessment consists of a relatively straightforward exploration of the patient’s presenting symptoms. Such inquiry might begin with a simple statement like: ‘What

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seems to be the reason that has led you to come here?’ or, even more briefly: ‘Tell me what brings you here?’ This would lead the patient to describe his or her predominant difficulties. The inter- viewer, after listening patiently for a while should summarize for the patient the main symptoms and, in doing so, organize the rele- vant clusters of complaints. For instance, the interviewer might say: ‘From what you have told me so far, it seems that you are ex- periencing three main difficulties: first, depression, including cry- ing spells, hopelessness, and occasional suicidal thoughts; second, an increasing alienation from your family involving disagreements about your boyfriend and your place of residence; and third, some confusion about whether you wish to continue your education or drop out from school altogether’. Such an intervention helps the patient organize his or her thinking, demonstrates to the patient that the therapist has already begun his work, and, by providing identifiable categories to the often diffuse distress, gives the patient an intellectual handle on it. It might limit the patient’s freedom somewhat, but this can be rectified by asking open-ended ques- tions pertaining to what one might have missed somewhat later in the interview.

Once the patient’s main symptoms are identified, more detailed investigation of each should follow. The account now provided by the patient might be fleshed out further by the interviewer’s asking more direct questions, preventing the patient from becoming too tangential, and exploring the presence or absence of secondary and related symptoms. In the case of depression, for instance, these might include excessive drinking, incapacity for caring for chil- dren, and manic episodes. As the details of each cluster of symp- toms become clear, the interviewer might begin thinking about the possible connections between the various clusters. However, it is preferable to keep such early hypotheses to oneself at this point.

While remaining reserved on this front, the therapist should by no means stay passive and non-directive. He should allow the pa- tient to elaborate and offer details but he should also feel free to stop the patient from going on and on about what has already been established. More importantly, he should not shy away from what appears difficult and anxiety-producing to the patient. In this con- text, the following reminder by Gill and Redlich (1954) is impor- tant.

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The technique of quickly leaving painful subjects of- ten is interpreted by the patient as a reluctance to at- tack major difficulties. A patient’s anxiety may even be heightened by the feeling that if the therapist is fearful, the problem must be serious indeed. A bold attack which shows that the therapist knows what he is about, that he can lay his finger on the trouble and is not afraid, may not only be very reassuring but may go far toward helping the patient overcome the ever- present tendencies to evasion, whether these are con- scious or not. (p. 31)

One area of pain and anxiety to which an entire section of this book (Chapter Five) is devoted pertains to suicide, which must be directly and fearlessly explored, especially when the patient’s pre- senting complaints involve depression. Similar forthrightness needs to be maintained vis-à-vis addictions and sexual deviations. The calm, unhurried but firm manner of the therapist lays the groundwork for the ‘working alliance’ (Greenson, 1965) within the dyad.

Level Of Character Organization

Assuming that the patient is non-psychotic (since the presence of psychosis aborts a dynamic interview and reverts it back to the tra- ditional psychiatric history-taking3), the essential task of this part of evaluation is to distinguish between neurotic and borderline lev- els of personality organization. Using the terms ‘oedipal’ and ‘pre- oedipal’ for these two groups respectively, Greenspan (1977) has outlined seven dimensions of personality functioning that help dif- ferentiate between them:4

(i) capacity for distinguishing internal versus external reality; (ii) cohesion, organization and resistance to fragmentation even under stress of the self and object representations; (iii) capacity for experiencing and perceiving a variety of discriminated affect states; (iv) level of defenses,(v) capacity to modulate impulses appropriate to external situation; (vi) capacity for gen-

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uine attachment and separation, and for the experi- ence of sadness and mourning; and (vii) capacity for integration of love and hate. (p. 385)

Within the interview situation, coming to grips with the above largely translates into the exploration of the following three areas.

(1) The degree of identity consolidation. In the neurotic character organization, there is a well-established identity while in the bor- derline organization there is identity diffusion (Kernberg, 1975, 1984; Akhtar, 1984, 1992a). The features of identity diffusion in- clude markedly contradictory character traits, temporal disconti- nuity in the self-experience, feelings of emptiness, gender dyspho- ria, subtle body-image disturbances, and inordinate ethnic and moral relativism (Akhtar, 1984). Not all of these features can be elicited and explored to an equal degree through formal question- ing. Some (e.g. feelings of emptiness) are more evident in the pa- tient’s complaints, while others (e.g. temporal discontinuity in the self-experience) become clear only through obtaining a step-by- step longitudinal account of the patient’s life. Still other features (e.g. subtle disturbances of gender identity) are discernible, at least in the beginning mainly through the overall manner of the patien- t’s relating to the interviewer. Yet it is helpful to ask the patient to describe himself. One might say something like this: ‘Now that you have told me about your difficulties, can you please describe your- self as a person?’ In the description offered by the patient, one should look for consistency versus contradiction, clarity versus confusion, solidity versus emptiness, a well developed sense of masculinity or femininity versus gender dysphoria, and a sense of ethnicity and inner morality versus the lack of any historical or communal anchor.

If the patient is unable to provide a coherent description, this should not be immediately construed as implying identity diffu- sion. This could be due to anxiety, lack of psychological minded- ness, cultural factors, poor verbal skills or low intelligence. These factors should be ruled out before making a conclusion regarding the presence or absence of identity diffusion in a given instance.

Sensing difficulty in the communicative path of the patient, the therapist might decide to help him by conducting the inquiry in a piecemeal fashion. For instance, he might ask about the patient’s

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religious beliefs, practices, and their continuity with what was handed down to him during childhood; feelings of ethnicity and of belonging to a certain regional or communal group; continuity of contact with friends and associates from earlier periods of life; clar- ity and stability of vocational goals; sublimations and hobbies; and so on. He may then surmise the status of the patient’s identity based on the information gathered. A patient might not be able to describe himself well, yet may turn out to posses a consolidated identity. Conversely, one might come across in a patient

peripheral areas of self-experience that are contradic- tory to a well-integrated, central area of subjective ex- perience, peripheral areas that the patient experiences as ego-alien or ego-dystonic, not fitting into his other- wise integrated picture of himself. These isolated ar- eas may be an important source of intrapsychic con- flict or interpersonal difficulties but should not be equated with identity diffusion. (Kernberg, 1984, p. 37)

(2) The nature of predominant ego defenses. The ‘neurotic’ or higher level character organization is characterized by the predominance of repression as the main ego defense and the borderline organiza- tion by the predominance of splitting and related defenses (Kern- berg, 1967, 1975, 1984; Volkan, 1976). Splitting manifests in five dif- ferent ways (Akhtar and Byrne, 1983): (i) inability to tolerate much ambivalence, (ii) intensification of affects, (iii) reckless decision- making process, (iv) ego-syntonic impulsivity, and (v) marked os- cillations of self-esteem. The individual using splitting tends to have an all-or-nothing approach to life. He sees good and bad as mutually exclusive. He is overly controlled or loses all control. He attacks the entire problem and gets overwhelmed or avoids the problem altogether and feels defeated. He has a tendency towards ‘now or never; murderous rage or total denial of anger; either my way or your way; either this way or not at all’ (Schulz, 1980, p. 184).

In the interview situation, the patient’s verbal productions, as well as his overall attitudes, give hints toward the existence, or more accurately, the predominance, of splitting. Confronting the

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patient with contradictions in the information provided by him and seeing his response also helps discern the tendency toward splitting. It may help distinguish borderline from potentially psy- chotic levels of organization (Kernberg, 1984). Demonstrating gross psychic contradictions (e.g. a Catholic nun moonlighting as a strip- per, a tongue-tied and shy individual being a stunning public ora- tor) to the patient leads in the former instance to anxiety and awk- wardness coupled with recognition of contradictions and a tem- porarily improved observing ego. In the latter, however, such con- frontation leads to a greater tenacity of compartmentalizations and recourse to increasingly odd ‘logic’ to defend the validity of keep- ing ill-fitting sectors of personality apart.

(3) The nature of object relations. Taking a detailed family history (including questions about parents and their marriage, siblings, and, if the patient is married, their spouse) provides an opportuni- ty to asses the patient’s capacity for meaningful object relations. The patient who has a higher level of character organization (e.g. obsessional, phobic, hysterical) shows the capacity for relating to others as truly separate individuals with their own strengths, weaknesses, and independent motivations. The one with a lower level character organization (1) gives premium to his own feelings (e.g. ‘I hate him’, ‘I find him adorable’) over the actual description of someone else (e.g. ‘My mother is a school teacher and a very kind person’), (2) uses extreme adjectives (e.g. ‘She is brilliant!’), (3) fails to take into account the concerns and motivations others may have independently of him, and (4) has few non-exploitative rela- tionships (as evidenced by lack of concern for nephews, nieces, and pets, i.e. from whom one can derive little direct benefit). When these features are prominent, the character organization is usually in the borderline range even though phenotypically the patient might appear to be functioning better. A marked presence of the fourth element is suggestive of antisocial personality disorder.

ASSESSING SUITABILITY FOR TREATMENT

Psychological Mindedness

A quick survey of the literature reveals that different people mean different things by ‘psychological mindedness’ or at least empha- size different aspects. Reiser (1971), for instance, delineated three

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components of psychological-mindedness: (1) sensitivity to sym- bolic meanings and to situational resemblances between life events in historical context, (2) empathy for others’ affective experiences, and (3) interest in human behavior and the motives that underlie it. He emphasized that psychological-mindedness, in contrast to cu- riosity, is inwardly directed. It is more passive, reflective, and re- ceptive than curiosity, which is driving and compelling. Lower et al. (1972) described psychological-mindedness as including ‘a ca- pacity for insight, introspective, intuition, verbality, remembering dreams and fantasies, awareness of transference, of internal con- flict; sensitivity to own feelings and curiosity about drives’ (p. 615). Applebaum (1973) proposed the following definition: ‘A person’s ability to see relationships among thoughts, feelings, and actions, with the goal of learning the meanings and causes of his experi- ence and behavior’ (p. 36). He distinguished such psychological in- terest for purposes of understanding oneself and others from the intellectualized, exhibitionistic, merely playful, or self-condemna- tory uses of introspection.

While these investigators do offer many ‘clinical pearls’, it is Coltart (1988) who provided the most detailed guidelines about the assessment of psychological-mindedness in the diagnostic inter- view. Though acknowledging that the whole is often greater than the sum of its parts, she outlined nine points ‘in an approximate or- der of discovery, rather than importance, under two headings’ (p. 819): the history, and developments in the interview arising from the history. Under the first heading, Coltart suggested that the di- agnostician should look for:

1. The capacity to give a history which deepens, ac- quires more coherence, and becomes textually more substantial as it goes on... 2. The capacity to give such a history without much prompting, and a history which gives the listener an increasing awareness that the patient feels currently related in himself, to his own story; properly—if unhappily—the product of the connective aetiology of his life’s circumstances... 3. The capacity to bring up memories with appropriate affects. (p. 819)

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Under the second heading, Coltart included the following:

4. Some awareness in the patient that he has an un- conscious mental life... 5. Some capacity to step back, if only momentarily, from self-experience, and to ob- serve it reflectively—either spontaneously, or with the help of a simple interpretation from the assessor, who should make opportunity for this sort of intervention... 6. A capacity, or more strongly a wish, to accept and handle increased responsibility for the self... 7. Imagination... 8. Some capacity for achieve- ment, and some realistic self-esteem... 9. Overall im- pression... something deeply recognizable, but ulti- mately not fully definable, about the assessor’s experi- ence of a thorough, intense, working consultation with a psychologically minded person. (pp. 819-820)

I am in agreement with Coltart. However, I think that she be- came a bit over-inclusive in listing capacity for achievement under psychological-mindedness. On the other hand, she did not include some other ways to assess the patient’s psychological-mindedness. For instance, a patient who has kept an ongoing journal displays a capacity for reflectiveness, a wish for psychic dialogue, and a re- spect for mental life. The same applies to a patient who sponta- neously offers a dream during the initial evaluation. This is espe- cially significant if the patient is not in the mental health field and thus not biased in that direction. Yet another evidence of psycho- logical-mindedness is the patient’s spontaneous offering of a ge- netic explanation of either his or her own or someone else’s behav- ior.

To summarize, it seems that psychological-mindedness is best reflected by observing the following things: (1) a capacity for reflec- tive self-observation as evidenced by the patient’s giving a coherent and affectively resonant history as well as by his or her ability to be aware (or become aware during the interview) of internal conflicts; (2) an interest in one’s mental life as evidenced by a history of having kept journals, and by spontaneously mentioning dreams and fan- tasies in the initial interview; (3) a belief in psychic causality as evi- denced by the patient’s offering a genetic explanation of his or her

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own or another’s behavior and by his or her capacity to entertain a mental basis for certain accidents, onset of a physical illness, and so on; and (4) a readiness to see symbolic meanings and enter into a metaphorical dialogue as evidenced by a positive, even welcom- ing, response to a trial interpretation.5

Two caveats are in order here. First, the presence of only one among these four factors should not lead to the conclusion that the patient is psychologically-minded. Two, an attempt should be made to distinguish an actual deficiency in psychological-minded- ness from its pallor due to anxiety in the interview situation. Sup- portive, empathic remarks may diminish the anxiety and improve psychological mindedness in the latter but not in the former in- stance.

Other Mental Functions

(1) Benign regression. In order to enter and benefit from dynamic psychotherapy, an individual must posses the capacity to renounce logic and reality on a transient and ego-replenishing basis. Without such ‘benign regression’ (Balint, 1959, 1968), psychotherapy tends to become a mere intellectual exercise. The way to assess this ca- pacity is ask the patient about their leisure time (e.g. Sundays, va- cations), their being able to have peaceful solitude, and their ability to play with children and pets.6

(2) Ego strength. Since dynamic psychotherapy can stir up latent conflicts and cause anxiety, it is important to have some sense of the patient’s ego strength. This can be ascertained by asking the pa- tient how he deals with stressful situations (e.g. examinations, job interviews, children’s illness) as well as by observing how the pa- tient conducts himself in the interview himself. Incapacity to toler- ate anxiety and poor impulse control are suggestive of a weak ego and, therefore, negative prognostic indicators in-depth psychother- apy.

(3) The ‘intermediate area of experience’. According to Winnicott (1953), the ‘intermediate area of experience’ refers to the psychic space where a confluence of reality and unreality occurs even though such matters do not form its content per se. It is where imagination is born and paradox reigns supreme. It contains phe- nomena that are subjectively experienced and are neither ques- tioned nor not questioned for their literal verity. Its clinical impor-

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tance lies in the fact that transference phenomena should stay within this area and not become too ‘real’ in order to be inter- pretable. Assessment of the patient’s capacity in this regard can be done by questions pertaining to the patient’s ability to play, create, and enjoy fiction, movies and poetry, all of which require a make- believe sort of mental attitude. His responses to the therapist’s ten- tative interpretations which offer imaginative ways of understand- ing his problems is also telling in this regard.

(4) Superego. Some assessment of superego functioning is also essential. A harsh superego makes the patient feel unworthy of deep and sustained help and prepares the ground for a ‘negative therapeutic reaction’ (Freud, 1923) once the treatment gets under- way. Resistance to uncovering deeper layers of psyche where anxi- ety, guilt, and shame-producing wishes and fantasies lurk can be strengthened by a strict superego. Too lax a superego can also pose problems, with the patient lying, withholding information, and misrepresenting financial resources in order to pay a lower than re- alistic fee for treatment.

ASSESSING FEASIBILITY OF TREATMENT

While the assessment of psychopathology yields information about the need for treatment and the assessment of psychological mind- edness, ego strength, and superego function yields information about the suitability for treatment, it is the assessment of the pa- tients motivation and his or her reality situation that reveals whether a meaningful treatment can actually be established.

Motivation

Patients who are themselves desirous of change are the ones most suited for in-depth psychotherapy. Recognizing, at least to some extent, their own role in the subjective and interpersonal distress they are feeling, such individuals are better prepared to take a look at their own selves with the psychic lens created in the therapeutic dyad. It should however be acknowledged, in all fairness, that most patients arriving at the psychotherapist’s door are not so pre- pared; they seek symptomatic relief. Here the assessment of self- concern as well as the concern the patient shows towards others who are impacted by his ‘symptoms’ is important. Finally, there are patients who seek treatment largely at the behest of an exhaust-

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ed spouse, irate parent, or disgruntled employer. The temptation to regard these patients as lacking motivation is great. However, sim- ply because the patient has been ‘forced’ to come by someone else does not automatically translate into lack of desire for change. Careful evaluation of each individual case in point is therefore in- dicated though with the following caveats in mind.

First, it should be remembered that motivation does not refer to conscious motivation alone. Klauber (1981) has eloquently made this point:

What commonly brings the patient is the pressure of his immediate suffering, usually on himself, but not infrequently on his doctor or his family. But in any case, his conscious motivation whether for analysis or against it, is only a partial indicator of his unconscious motivation. It is his unconscious motivation which has to be determined—the repressed wish, so to speak, behind the manifest content of his presentation and the relevance of this wish to the present crisis in his life. (p. 151)

Second, those individuals who seem very well-motivated for change sometimes turn out not to be so; a nucleus of hard resis- tance at times dwells deep within their psyche. Patients who have extensively read psychiatric and psychoanalytic literature and seem gifted in their grasp of unconscious trends at times turn out to be operating largely from a false self constellation (Balsam, 1984). Others, while appearing quite devoted to the therapeutic en- terprise reveal tenacious ‘some day…’ fantasies of an entirely con- flict-free existence that keep them from being truly involved in a process of psychic change (Akhtar, 1996). Sadly, these resistances are not infrequent among those working in the mental health field.

Third, those who claim to have been pushed to seek treatment by others might have unconsciously engineered such referral by in- cremental doses of unacceptable behavior. The help-seeking cry of others on their behalf reflects the repudiated healthy parts of their own personality; these have been deposited into others by ‘healthy projective identification’ (Hamilton, 1986). The following observa- tion by Armstrong (2000) pointedly underscores this dynamic.

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The man sent by his spouse or the woman sent by her sister must have felt some inkling of pain, some un- conscious connection with the relative’s complaint to seek the treatment. It will be the therapist’s task, one more difficult than with the person who is self-moti- vated, to locate that pain. (p. 161)

Finally, while motivation is an attribute that the patient brings with himself, it can also be ‘co-created’ during the clinical en- counter. The therapist’s grasp of the patient’s inner reality can, at times, mobilize the patient in new and powerful ways.

CLINICAL VIGNETTE 4 Norman Liebowitz, a thirty-two year-old internist from a regional medical center, came to see me for ‘de- pression’. From all external appearances, he seemed successful: he was young, handsome, financially sta- ble, and physically healthy. He was also happily mar- ried and recently had become a father. It was this last epoch that I felt had, paradoxically, triggered the de- pression he was feeling. Support to this line of think- ing was given by the account of prior masochistic mishaps associated with his graduation from college and from medical school.

As the interview proceeded, Dr. Liebowitz abruptly stopped and said while all he had said so far was true, there was something else that was troubling him even more. This ‘something’ had been with him for many years but he had never been able to talk about it with anyone. I responded by gently encouraging him to say more about what this hidden problem was and also about the concerns that had led him to keep it a secret. After some hesitation, Dr. Liebowitz revealed that he liked to chew upon cats’ nails. He would frequent the houses of friends and acquaintances and, at times, scout the neighborhood to find a cat. Holding the ani- mal up in his arms, he would bite off a chip from its nails. He kept these bits and pieces in a glass vial and

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chewed upon them at his leisure. As the interview progressed, a second interaction with cats emerged. He liked to bring a cat’s face very, very close to his own face and then breathe in the air that came out of the cat’s nostrils. Both these acts gave him deep grati- fication though he also worried about their apparent oddity and did not quite know what to make of them.

The next day, while describing his family back- ground, Dr. Liebowitz came upon the topic of his mother. He sighed, saying: ‘You don’t want to know about her. She is so controlling and so intrusive that I cannot describe. She lives about a thousand miles from here but I constantly feel her claws digging in to me.’ As he said this, he grabbed the upper part of his left arm with his right hand, making the latter appear like a claw, and dug his nails into the skin. Seeing the connection between the biting off of a cat’s nails and the alleged claw of his mother on his arm, I said: ‘Did you notice what you just said?’ He was puzzled. ‘What?’ he responded. I said, ‘What do you make of you using the word “claws” in connection with your mother and how do you connect her “claws” with a cat’s nails?’ He was dumbfounded but gradually be- came somber and began to talk about his chronic diffi- culty of maintaining an optimal distance from his mother. With further elaboration during the session, the biting off of the cat’s nails and breathing the air coming out of the cat’s nostrils could be seen to sym- bolize the two sides of this distance-closeness conflict. As this clarification settled in our dialogue, I could see him become more animated and curious about his in- trapsychic life.

In the end, it seems that the issue of motivation is far from sim- ple. The categorical division of ‘motivated’ or ‘unmotivated’ pa- tients should therefore be put aside in favor of the following di- mensional queries. What aspect of his psychopathology is the pa- tient motivated to get help for? What has caused this motivation? What is his conscious motivation and what is his unconscious mo-

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tivation? How can one mobilize forces within the patient to en- hance his motivation for psychic growth? What fears, concerns, and self-defeating tendencies might be responsible for his low mo- tivation? To what extent, these can be brought to the patient’s awareness and with what beneficial result? And so on. It is this kind of a broad-based and thoughtful approach to the issue of the patient’s motivation that yields more productive information.

Reality Factors

The psychotherapeutic enterprise, despite its imaginary and imagi- native dimensions, must be firmly anchored in reality. This is not only true vis-à-vis the therapeutic framework and the interperson- al boundaries it is dependent upon (see Chapter Two for more de- tails) but also applies to the very fact of taking a patient into treat- ment. In other words, certain realistic conditions must be met be- fore one agrees to treat a patient in intensive psychotherapy. Some certainty of sustained financial resources, for instance, is necessary. Without a proper investigation of this, the treatment at times comes to a screeching halt and, because a psychodynamic process involving transference and countertransference has been set into motion by this time, it becomes very difficult to sort out the role of the reality impediment in the continuation of care. (See Chapter Three for more details on the role of money in psychotherapy.)

Another requirement is that the patient resides within a reason- able distance of the therapist’s office. A patient who lives far away might make earnest promises to maintain regular attendance for the sessions but generally fails to do so once the difficulty of travel meets the inevitable resistance to psychological uncovering. Thera- pists who are financially or otherwise needy are as vulnerable to compromises of judgment in such situations as are the renowned and charismatic ‘specialists’ sought out by long distance patients.

While by and large it is inadvisable to take patients who live a long distance away from the therapist’s office, there might be ex- ceptions to this rule. Three such situations are: (i) the distance is rendered manageable by rapid means of transport, (ii) there is no adequately trained psychotherapist in the patient’s vicinity, (iii) the patient is a mental health professional for whom the treatment is a part of psychoanalytic training and there is no training analyst where the patient lives or works. To be sure, problematic scenarios

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can lurk in the background of these situations as well but they do require a more sympathetic consideration than where the pressure to be treated by a particular, usually renowned, therapist is mostly based on the idealization of him.

In these latter circumstances, the capacity of the therapist to contain and manage the prospective patient’s idealization becomes crucial. A highly nuanced approach is needed in dealing with those who call after reading a book one has authored or after hearing a lecture one delivered somewhere out of town. This approach must avoid the extremes of defensive recoil and refusing to see the pa- tient altogether or getting seduced into starting a treatment under unrealistic circumstances. Rather than rejecting the patient, the therapist might offer a consultation of about two to three hours in length (with or without a short break) with the explicit statement that this would not lead to an on-going treatment. Such consulta- tion should encompass not only the tasks outlined above but also explore the patient’s idealization of the therapist with the hope to bring it to a temporary closure; the reasons for it can be understood and resolved in a future treatment under more realistic circum- stances.

A different problem is presented by individuals who seek out of town treatment because they themselves are pillars of their society and cannot afford to be ‘discovered’ seeking help. While excep- tions exist, a consistent exploration of their vulnerability to shame can help them overcome this resistance.

CLINICAL VIGNETTE 5 Max Robinson, a sixty year-old wealthy businessman from a small city some one hundred miles away from my office, consulted me in the midst of a marital cri- sis. His wife had discovered that he was having an ex- tramarital affair and had threatened to divorce him. As matters got more heated, the prior occurrence of two more infidelities came out. Asking for her forgive- ness, Max told her that he had been emotionally trou- bled for a long time and would seek psychiatric help.

The evaluation that followed revealed a history of much greater sexual promiscuity than these three af- fairs suggested. Max had been restless for years and

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his sexual escapades had taken place in the setting of chronic boredom. Placed alongside a distinguished work record and overall stability of personality func- tioning, such contact hunger, coupled with a nearly total inability to love anyone, suggested the possible diagnosis of narcissistic personality disorder. I made a recommendation of psychodynamic psychotherapy on a twice a week basis with the consideration of con- verting it to psychoanalysis in the future. Clearly, it was not possible for him to undertake this treatment with me since he lived quite far from my office. Fortu- nately there was a psychoanalyst who practiced in his town; this was someone I knew and respected. The patient, it turned out, was unwilling to see this ana- lyst, claiming he would be profoundly ashamed if someone in town saw him go in and out of a ‘shrink’s’ office. This gave me an opportunity to explore the feelings of inferiority that were hidden inside of him and had, in part, fueled his promiscuity; the idea was that if a woman agreed to sleep with him, he must not be all that bad. As we were able to link his hesitation over going to the local analyst with his chronic self- doubt, Max’s opposition to my recommendation di- minished.

RECOMMENDING TREATMENT

Once the core information about the patient’s psychopathology has been gathered, his suitability for dynamic psychotherapy deter- mined, and a sense of whether such treatment is realistically feasi- ble has been gained, the therapist is in the position of making a rec- ommendation. While there are always exceptions in the clinical sit- uation, the choice, at this point, between recommending psycho- analysis, psychodynamic psychotherapy, or supportive interven- tions rests upon a telescoping of the three sets of information (psy- chopathology, ego and superego functions, and motivation and re- alities) into a composite gestalt. This does not rule out the fact that the patient’s symptoms alone can, at times, affect the choice of treatment modality. For instance, three types of symptoms should

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give one pause while recommending in-depth treatment, be it psy- choanalysis proper or psychodynamic psychotherapy. These in- clude (i) symptoms that are bizarre (e.g. communication with ex- traterrestrial beings); (ii) symptoms that are pleasurable (e.g. exces- sive drinking, sexual promiscuity in younger narcissistic patients); and (iii) symptoms that stand by themselves and are tenacious (e.g. monosymptomatic hypochondriasis). This last point has been made most emphatically by Klauber (1981) who states that ‘the lack of capacity for varied forms of displacement implies a near- delusional mechanism’ (p. 155).

All in all, the patients who have a mild to moderate degree of psychopathology, a higher level of character organization, out- standing psychological mindedness, good ego strength, well inte- grated superego, strong motivation, and relatively easy realities, should be taken into or referred for psychoanalysis proper (Bachrach & Leaff, 1978; Rothstein, 1982; Zimmerman,1982). Those patients who have moderate to severe psychopathology, an overall borderline level of personality organization regardless of its pheno- typical picture, high or medium psychological mindedness, some compromise of ego and superego functions, moderately strong mo- tivation, and only somewhat compromised realities, should be re- garded as being suitable for psychodynamic psychotherapy. Final- ly, those who are very severely ill, betray a psychotic level of char- acter organization, have medium or low level of psychological mindedness, moderate to severe impairment of ego and superego functions, weak motivation, and difficult realities, should be treat- ed with supportive interventions including the adjunct measures of medications, group interventions and even hospitalization. However, these guidelines must be treated as such and not turned into rigid rules. Their aim is to underscore the plausibility of differ- ential therapeutics in this realm, not to box in the clinician in pre- fabricated and inviolable categories.

Once the therapist has arrived at such clarity, he should inform the patient that his diagnostic evaluation is over and share his con- clusions with the patient in simple, jargon-free language. He might include in his comments hints of how he arrived at his conclusions. Quoting something the patient had said, recounting a particular emotional outburst, and reminding the patient of a slip of the tongue enhance the patient’s sense of participation and mutuality

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even at this phase. This, in turn, facilitates the patient’s receptivity to the information being given.

Two other things should be kept in mind. Firstly, it might be good to preface one’s comments with the caveat that conclusions arrived at in one to three sessions are necessarily tentative. The in- terviewer might also indicate at this time the need for further in- vestigations of a social (i.e. family interview), psychometric, or lab- oratory kind, if he thinks that these might help to clarify the situa- tion. Secondly, while using ordinary language is preferable there is no reason to be wishy-washy or apologetic if a patient asks for a specific psychiatric diagnosis. Exploring the patient’s reasons for asking this might reveal further, significant information. However, such exploration should not be used as a delay tactic, and a patient who wants to know his diagnosis should be told. The emphasis in statements made to the patient must, however, remain upon the patient’s subjective experience and not upon the behavioral con- comitants typical of the nosological entity though these might have to be included as well. The following ways of explaining border- line and narcissistic personality labels illustrate this point well:

Borderline personality disorder. ‘As we grow from a child to an adult, we develop two capacities: one is to want and need “good” things, such as “good” relationships, “good” love, “good” sex, “good” job, “good” house, and so on. The other ca- pacity we develop is to tolerate the disappointing fact that we will not get “good” stuff all the time. The individual who has a borderline personality disorder has the first capacity but lacks the second one. As a result, when faced with disappointments, he gets very hurt and like any other person who is frequently hurt, he gets angry. This anger comes in the way of the mind’s peaceful functioning in the realms of both his relationships and vocation. Life gets splintered and is lived in pieces. At times, the individual vents his rage on self and others or tries to get rid of it by numbing his mind (with the use of substances) or distracting himself by impulsive gratifications. All in all, bor- derline personality disorder is a very painful condition to have.’

Narcissistic personality disorder. ‘The person with a narcissistic personality disorder is someone who is preoccupied with his

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own self. While it might come across as such, this is hardly a matter of vanity. The fact is that the person secretly feels quite worried about his own self and carries a profound vulnerability to shame. Having been raised on praise without much love and affection, such a person has become dependent upon admira- tion. This is what he constantly seeks. He feels perpetually com- pelled to improve his talents, polish his image, and “sell” him- self to others. Now, all this takes a lot of effort, and energy. It is truly tiresome. Besides it has the painful consequence of his be- coming unable to pay attention to others and also not feeling re- ally loved by anybody; he feels that people like him only be- cause of what he has accomplished not for who he is. He feels alone in this world. While socially successful and admired by others, the narcissistic person lives in a private world of self- doubt, inferiority and insatiable longing for genuine love and acceptance.’

This manner of telling the patient’s diagnosis to him should put to rest the prevalent notion that patients misunderstand diagnostic terminology and are narcissistically injured by it. In holding onto this old-fashioned idea, one is liable to overlook that the interview- er’s cryptic attitude, fudging, and uncomfortable avoidance can also have alienating and adverse effects on the patient.

Following the discussion of the nature of the patient’s problem, the focus should shift to issues of its treatment. The interviewer should now inform the patient of what he thinks is the ideal treat- ment for the patient’s malady, explaining, especially if asked, the reasons for this recommendation. The patient should also be in- formed, especially if things are unclear, of alternate approaches to treating the condition involved, and encouraged to ask questions about anything that seems unclear Questions raised by the patient should be answered factually, and the interviewer should not de- rail or mystify the patient by ‘interpreting’ the reasons behind such questions. For instance, the patient may ask why the frequency of two to three times a week is needed for dynamic psychotherapy. Or, he might ask about the difference between psychoanalysis and psychotherapy. Subtle controversies in the field notwithstanding, it is possible to answer such questions in a simple, straightforward way. Regarding frequency, one might say the following: ‘the prob-

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lems we are dealing with here are deep and solving them requires the sort of access to your inner world that can only be provided by such frequency.’ One might explain the difference between psycho- analysis and psychotherapy not only in terms of frequency of visits and the use of couch but, to a certain extent, in terms of the nature of the patient’s activity (i.e., free association) and the therapist’s ‘quieter ’ stance vis-à-vis the patient’s report of his thoughts, feel- ings, fantasies, and dreams. In the end, it is the therapist’s straight- forward and collaborative manner in dealing with the patient’s questions that counts.

CONCLUDING REMARKS

In this chapter, I have attempted to offer an account of what consti- tutes a thorough initial assessment of a potential patient for psy- chodynamic psychotherapy. I have divided my comments into the categories of (i) forming early impressions, (ii) assessing psy- chopathology, (iii) assessing psychological mindedness and other ego functions, and (iv) assessing the patient’s motivation and reali- ties that might impact upon the feasibility of proper treatment.7 I have described how pooling the four sets of data helps choose a treatment modality and then described the process of making rec- ommendations to the patient, answering his questions, and, through all this, beginning to set the ground rules for treatment be- ing undertaken.

Conducting these tasks is hardly restricted to gathering objec- tive information; the therapist’s subjective experience plays a key role throughout the evaluation process. Indeed, vigilance towards early ‘countertransference’ yields all sorts of useful clinical data, as I have already shown in this chapter. What I wish to underscore now is that while the arousal of strong feelings in the therapist does not necessarily preclude his taking the patient into on-going treatment, circumstances where this might be the case do exist. In- tense discomfort with a patient based upon cultural differences and/or the nature of psychopathology at hand might, at times, not be ‘containable’ by the therapist’s work ego. Instead of becoming unduly valiant, it might then be preferable not to take the patient into treatment. Politics, the last taboo in the clinical field, can also contribute to insurmountable difficulties. Finally, there is the issue

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of the therapist’s competence to treat a particular patient. While all sorts of professional and legal checks and balances exist in order to assure this, ultimately the assessment of one’s competence rests upon a honest self-scrutiny and fearless soul searching.8

This brings up the fact that in-depth psychotherapy constitutes an intrapsychic and interpersonal journey that is unpredictable and, at times, dark and mysterious. Two people undertaking such a trip together need to establish and maintain clear limits and boundaries to prevent themselves from getting derailed. This forms the topic of the next chapter.

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