Neuropsychoanalytic Diagnosis ( Part 5 )

These internal conflicts and/or external traumas experienced the child's development stages may have led to painful symptoms of anxiety, depression, panic, flashbacks, obsessions, fears, etc. Neuropsychoanalysis teaches that these unpleasant feelings result from faulty, repressed, childhood predictions that were not adequate to successfully resolve childhood conflicts..... Defenses are then required to ward off these unpleasant feelings.  There are three levels of defenses:  They may be neurotic, narcissistic/borderline, or psychotic. The higher level neurotic defenses are more likely to succeed in defending against the unpleasant feelings than are the  narcissistic/borderline ones. And the narcissistic/borderline defenses are more successful at defending against bad feelings than the psychotic ones......When any of these three levels of defenses fail, the patient experiences the "return of the repressed" in the form of troublesome feelings. These troublesome feelings are the symptoms that bring patients to treatment. These symptoms are grouped together in the various diagnoses of anxiety disorders, depressive disorders etc., of the DSM......Neuropsychoanalytic diagnosis sees these unpleasant feelings/symptoms as the result of unmet basic emotional needs, which result from the faulty repressed predictions mentioned above. It is the assessment  of these faulty predictions  that is key in neuropsychoanalytic diagnosis, because it is the faulty predictions that are the cause of the patient's inability to meet their basic emotional needs .  The inability to meet these basic emotional needs results in the unpleasant feelings which are the psychopathology. Changing the faulty predictions to healthy, workable predictions then becomes the  goal of neuropsychoanalytic  psychotherapy. These changed predictions lead to mental health. 

Neuropsychoanalytic Diagnosis ( Part 4 )

 When the therapist is making a neuropsychoanalytic diagnosis of the patient's underlying problems, they look deeply into the client's early childhood experiences and how those experiences have affected their development. Depending on their age, developmental level, severity of their childhood difficulties, and current life stressors, the patient may develop one of the following three types of disorders.  These  are: Neurotic Level Disorders, Narcissistic/Borderline Disorders, and Psychotic Disorders. Neurotic level patients are rather high functioning persons.  Narcissistic/Borderline level patients, however, are quite ill, and Psychotic patients are severely disturbed. Neurotic patients may have experienced internal and/or external conflicts later in childhood around the ages of 3-6 years old. Neuropsychoanalysis adds that the basic emotional need that most demands to be met at this level is PLAY. Playing in neuropsychoanalysis includes relating to persons as individuals, family members, or members of groups. When the PLAY need is not adequately met neurotic disorders may result. Narcissistic/Borderline patients may have experienced such conflicts at the earlier age of 2-3 years old. The basic emotional need that demands to be met at this stage is RAGE, or the need to remove impediments life that prevent  you from meeting your basic emotional needs. When children cannot adequate remove obstacles from their lives narcissistic /borderline disorders may occur. Psychotic patients may have experienced  conflicts in infancy, but also suffer from  inherited brain illnesses. The basic emotional need demanding to be met at this time in life is PANIC/GRIEF or Attachment. The attachment need is the need for a secure loving relationship with mother and/or Father in childhood, and  then significant others in adulthood. When the need for secure attachment in infancy is not met, a psychotic disorder  might develop...... These three levels  of psychopathology may further be influenced by conflicts in all the developmental stages as well as those that result from current life stressors. 

1David Moore

Neuropsychoanalytic Diagnosis ( Part 3 )

Given your DSM symptom based diagnosis of Major Depressive Disorder, your Psychiatrist will decide which antidepressant medication would be best for reducing your painful symptoms and will prescribe that medication for you. They will hopefully also refer you to me for neuropsychoanalytic psychotherapy. ( Your psychiatrist is also a mental health professional and may offer you psychotherapy and/or medication.) So let's say your Psychiatrist prescribes you the anti depressant drug Lexapro and refers you to me for psychotherapy. When you come to see me for your first session I will also learn about what unpleasant feelings you are suffering from, and I too will conclude that you are suffering from Major Depressive Disorder. But neuropsychoanalytic diagnosis goes beyond the descriptive diagnosis of the DSM. 

1Natalie Melton

Neuropsychoanalytic Diagnosis ( Part 2 )

The DSM ( Diagnostic Manual of Mental Illnesses) is the official manual of mental health disorders used by all mental health professionals to diagnose their patients. Your psychiatrist also uses a version of this manual to diagnose your mental disorder. This manual, like the manual for physical illnesses, is based in an assessment of your symptoms. If you come to me or your psychiatrist  we are going to ask you about your symptoms. " What hurts? In what way does it hurt? How long have you been hurting?  What unpleasant feeling are you suffering from? "Let's say you answer the questions this way: " I am having trouble sleeping. I have lost weight. I have been crying a lot. I feel sad. I do not want to do anything. I have lost pleasure in everything. I have no joy. I feel worthless and I sometimes feel that the world would be a better place without me. I have seriously thought of suicide." Your psychiatrist  and I will both know that these are the symptoms of depression and we will diagnose you with a depressive disorder. We will choose the depressive disorder found in in the DSM  that best describes your symptoms. In this case we would diagnose you with Major Depressive Disorder. ( More to come. )

2Bill Huffman and David Moore

Neuropsychoanslytic Diagnosis ( Part 1 )

I want to write now about Neuropsychoanalytic Diagnosis. I have written earlier about theory and treatment, but as neuropsychoanalyst Mark Solms says, we cannot know how to help someone get better if we do not know what has gone wrong in their lives in the first place. This is the process of diagnosis......... Neuropsychoanalytic diagnosis is similar in some ways to DSM (the Diagnostic Manual of Mental Disorders)  diagnosis. We listen, observe, interview, get to know the patient in depth, rule out various diagnoses, and finally arrive at what is going wrong in their lives that needs to change in order for them to live a healthier life. Much of the beginning phase of therapy is about coming up with the correct diagnosis......In these next few posts I am going to write about how neuropsychoanalytic diagnosis starts out similarly to DSM diagnosis. But stick around for parts  two through five where I will talk about how different the two are as well!

8Loyd Allen, Christie Melton Kearney and 6 others

1 Comment

Like

Comment

Share

My Experience as a Supervisor of Neuropsychoanalytic Psychotherapist Students (Part II )

The approach I take with the student supervisee that I spoke of in my earlier post, is basically the approach that I continue with all my students--one week of teaching and one week of supervision over the duration of their supervision experience. So instead of writing about how the supervision of all students is different and how I adjust the supervision process to each one's particular needs, etc., I am going to write about what their supervision processes had in common.

Let me start with the books I used to help me further learn how to supervise. The first one is Clinical Perspectives on the Supervision of Psychoanalysis and Psychotherapy (1984), edited by Leopold Caligor, Philip Bromberg, and James Meltzer. The second book is Learning Process in Psychoanalytic Supervision: Complexities and Challenges (1987) by Paul DeWald. The third text was written in 1995 by Daniel Jacobs, Paul David, and Donald Jay Meyer. It is  titled, The Supervisory Encounter. The fourth supervision book is  Glen Gabbard's Long Term Psychodynamic Psychotherapy( the last chapter on Supervision.) The final text I studied is  entitled, The Supervisory Relationship, written in 2001 by Mary Gail Frawley-O'Dea and Joan E. Sarnat. In addition to these books I have read various articles and papers on  supervision that came my way through journals, etc. One of those is  by Otto Kernberg, published in 2010, Psychoanalytic Supervision: The Supervisor's Task.  For neuropsychoanalytic supervision in particular, I used my Training Manual, An Introduction to Neuropsychoanalytic Psychotherapy, which includes a section  on how to present case material. 

All of theses sources are  helpful, but even more helpful is hearing cases presented at neuropsychoanalytic conferences, and further hearing how the analysts/therapists would supervise the person presenting the material. These are not formal ongoing supervision sessions, but I find them very helpful in seeing how the analysts/therapists doing the supervising  listen, formulate, and comment on the case material. As enriching as all of these readings and experiences have been in doing supervision, they do not specifically address how to teach neuropsychoanalytic theory, practice, and technique to students. For this task I also attend conferences and read articles on psychoanalytic teaching. Over time I have developed a notebook with my charts, notes, diagrams, etc., that helped me teach my students about theory and practice. 

Of course the main way a student learns how to do neuropsychoanalytic psychotherapy is by "actually doing it." Neuropsychoanalytic therapy  training is tripartite. It consists of didactic courses, supervision, and your own personal or training psychotherapy. Although I have  not required  personal psychotherapy for my students, I have strongly encouraged  it. But in the end it is the fourth element of training that teaches the students the most, and that is their experience with their patients in the room, week after week, in neuropsychoanalytic treatment. I will say more about that next time.

My Experience as a Neuropsychoanalytic Psychotherapy Supervisor ( Part III)

The beginning phase of neuropsychoanalytic  psychotherapy supervision is similar to but different from the beginning phase of neuropsychoanalytic psychotherapy. It is similar in that the primary goal of the beginning sessions is all about forming a relationship with the student. In psychotherapy we call this the forming of a therapeutic relationship or a therapeutic alliance. In supervision we call it forming a supervisory relationship or a learning alliance. The relationship building part of the beginning phase requires the same skills of the supervisor as it does of the therapist. And from the student side, it requires the same amount of trust that forming a relationship with their therapist requires.

The major difference is the goal and purpose of supervision verses therapy. Supervision is not a therapeutic experience. It is a learning experience. It is not a therapist to patient relationship. It is a teacher to student relationship. We call this the "teach versus treat" goal. It is very important that the supervisor and the supervisee know the difference in the two forms of encounter.

Now what is unique about psychotherapy supervision, unlike other teacher/student relationships, is there is an element of therapy in the teaching. Because the teacher is also a therapist, they use their understandings and skills to help the supervisee see some things about themselves that would be off base to share in any other teacher/student dyad. For instance, if the supervisee makes a huge mistake in treating one of their patients, and the therapist believes it is because the supervisee's own personal issues got in the way, then they will tactifully point that out to the student. But they will not go into depth about the student's personal issues as if it were a therapy session. Instead they will say something like, "If this personal issue continues to get in your way then you might want to bring it up with your therapist." This is why it is so important that the supervisee also have a therapist as well as a supervisor. In addition to forming a learning alliance with the student therapist, the supervisor will also want to learn as much about the student's history of learning psychotherapy as possible. So the supervisor asks all about how the student became interested in therapy, what types of therapy have they themselves been in, what courses have they taken, where do they feel are the gaps in their knowledge, how much therapy have they actually conducted and what types, etc? During this time of history gathering the student may tell the teacher many personal and private things about themselves as well. The teacher listens empathically to the student as if these were therapy sessions, but the teacher does not dwell on these more personal experiences. The focus remains educational and not therapeutic. When does the beginning phase of supervision end? When the supervisor and supervisee feel they are quite comfortable with each other, and their relationship is no longer something they are focused on.

The beginning phase ends when both participants are caught up in the treatment of the supervisee's patients and the patient becomes the major focus of the sessions. Then the dyad has moved into the middle phase. The middle phase in psychotherapy is called the "working through phase." I would call the middle phase in supervision the "working on" phase, meaning the student and the teacher are both now working on the student's provision of therapy for the patient. The student is "working on doing it." The teacher is "working on teaching it." Learning is taking place. The supervisee is learning how to do psychotherapy. It is during this middle phase that the major problems of supervision come up. The student's personality sometimes helps the therapy process and sometimes gets in the way of it. It is the same with the supervisor. Their personality sometimes enhances their teaching and sometimes hinders it. These learning difficulties, problems, conflicts, and misunderstandings have to be worked on in the supervision, just as they have to be worked through in psychotherapy. It may be that both teacher and student have to consult a third party to clear up some problems in the supervisory work together. Sometimes the supervision problems cannot be worked out and the supervision ends before completion. Hopefully that does not occur and the supervisory dyad moves into the third and final phase of supervision, the ending or termination phase.

The termination phase is marked by the time in supervision when both the supervisor and the supervisee believe that the supervisee has learned all they can learn from the supervisor, and they are now feeling that they can function independently of the supervisor as a junior colleague or beginning independent therapist. Sometimes this ending is determined by a set number of supervision sessions required for licensure. At other times it is a free decision between the supervisor and the student therapist. No matter how the ending is determinded, ending supervision is not unlike ending therapy. It is all about wrapping things up, summarizing gains, celebrating victories, accepting failures, and ending the supervisory relationship. Like in therapy this ending needs not to be rushed. I would say it takes three to six months to successfully end five years of supervision. A major part of supervision termination, like in therapy termination, is grief. Both the student and the teacher will hopefully grieve the loss of the relationship, and this grief needs to be acknowledged and talked about. Of course both members of the dyad will also be celebrating as the student comes to "graduate" from supervision and becomes an independent therapist. For the supervisor it is not unlike having a child transition from young adulthood to mature adulthood. The student may indeed feel the same type of growth process and outcome. It should be a happy day when the former supervisor and the former student celebrate together the former student's receiving of their license to practice psychotherapy on their own! Ask a question!! Make a comment !! Tell me who you are !!