Case Discussion 1
I had the pleasure of providing 14 sessions of psychodynamic psychotherapy for A, a 22-year-old Pentecostal Christian Australian female who was referred by the local Early Intervention Psychosis Service (EIPS).A’s key issues include a fragmented sense of self, low-self-esteem and anxiety which pervades into various domains of her life, stating that she is ‘struggling with my purpose and where I am supposed to be and what I am supposed to be doing’. ASSESSMENTA lives at home with her divorced mother and two older brothers aged 26 and 24. She completed Year 12, took a gap year and then studied Certificate III and IV in Animal Studies at TAFE in the hopes to become a vet nurse before withdrawing her studies prior to completion. She also worked a casual job as a shelf stocker at a supermarket for 2 years and then a register at a warehouse for 2 years after that. She had an 8-month period out of employment following her psychiatric admission in mid-2023, and returned a few months ago. She attends church every Sunday and got baptised in 2022. Her supports are limited to people at her church. A historically attracted multiple diagnoses including Depression, Anxiety, Post-traumatic Stress Disorder (PTSD), Other Specified Feeding or Eating Disorder (OSFED) and Attention-deficit/1Hyperactivity Disorder (ADHD) with previous engagement with the local Child and Adolescent Mental Health Services (CAMHS) in 2015 - 2016, outpatient eating disorders program in 2020 – 2021 and psychologist at Headspace in 2021 – 2023. A did not find previous psychological interventions helpful, due to feelings of overwhelm particularly with cognitive behavioural therapy (CBT), difficulty opening up to new psychologists and via TeleHealth, and mother unable to bring her into appointments.A had one psychiatric admission for treatment of Reactive Psychosis in mid-2023. At this time, she was voluntarily brought into the Emergency Department after she was found to be lying on the driveway and speaking incoherently by her neighbour who then called the ambulance. She was severely disordered in thought form, stating that she was ‘not safe, not safe’ and that she had ‘too many different sources going around in my head and getting confused’. A few months leading up to this admission, A had been feeling overwhelmed having terminated her TAFE course, struggling with customers at her workplace, looking after her sick cat, resuming contact with her previously abusive father and dating a male who did not share the same religion as her. During the admission, A was visited by her father during this admission where she was noted to be visibly uncomfortable when father touched her, barely speaking to him with minimal eye contact and head down most of the time. She became nervous during EEG and reported flashbacks of her father hurting her, asking a nurse if her father was there and going to hurt her again. A was born as the youngest of three children in a Christian family, and she lived with her parents and two older brothers until her parents separated when she was 5 years old. There was a legal determination that the family lived in a shared custody arrangement where the children stayed in the same house while the parents rotated as to who would stay at home with the children. A described her family dynamics during childhood as ‘complicated’, describing her father as ‘violent’ and her mother as ‘’controlling’. There was domestic violence between the parents, as well as emotional and physical abuse perpetrated by her father towards her and her older brothers which she witnessed. A DCJ report was made in 2010 but the case was dropped. A’s mother had been the sole carer of the three children in more recent years, and A had intermittent contact with her father. A avoided seeing her father by saying that she had assignments or felt unwell. Her relationship with her mother became strained as she felt unsupported by her mother during her father’s abuse. She felt that her mother was depriving her of love and physical affection, unable to remember the times her mother hugged her during childhood. She describes her relationship with her mother as a ‘love-hate relationship’. A’s father has not acknowledged or apologised for his mistreatment of their family to this date. A’s two older brothers also had previous engagement with CAMHS themselves, with her oldest brother being diagnosed with Bipolar Affective Disorder and her second oldest brother being diagnosed with Depression. They have also distanced themselves from their mother despite living in the same house, with the second oldest brother installing a lock in his bedroom to prevent his mother from entering. A received learning support throughout schooling and felt ‘different from other children’. She briefly experimented with alcohol and tobacco when she turned 18. A’s education and employment were further disrupted by multiple physical health conditions including migraines with aura, polycystic ovarian syndrome, Wolf-Parkinson-White syndrome with patent foramen ovale requiring ablation in 2019 and leg discrepancy with chronic back pain requiring corrective surgery in 2023. She had engagement with a neurologist, gynaecologist, cardiologist, psychiatrist and physiotherapist due to the complexities of her co-morbidities. On assessment, A was a young, overweight Caucasian female. Her natural blond hair was dyed black with regrowth. She was conservatively dressed in dark unisex clothing and glasses. She appeared anxious - voluntarily shaking her legs, clutching her bag, pulling her hair, avoiding eye contact and awkwardly laughing. Cognition was grossly intact, alert and orientated to time, person and place. Her speech was soft and slow with reasonable fluency, articulation and enunciation. There was no formal thought disorder. Her thought content primarily surrounded her struggles to find purpose and meaningful relationships, as well as cognitive dissonance between who she should be and who she wants to be. She had an unresolved conflict arising between her rather concrete religious beliefs and her sexual desires. She reported her mood to be low with cognitive schema that she is ‘not good enough’ and that the world is not safe, and her affect was anxious and congruent. She denied any perceptual disturbance. Her insight and judgement were fair. A’s presentation is best conceptualised as a reactivation of her PTSD. Differential diagnoses include Major Depressive Disorder (MDD), Generalised Anxiety Disorder (GAD), Borderline Personality Disorder (BPD) and less likely a primary psychotic disorder. A was commenced on a combination of low-dose antidepressant and antipsychotic. FORMULATIONA has been unable to form a secure sense of self in a persistently invalidating and unsafe environment during her early relational and emotional development. A’s distress is precipitated by the pressure inflicted on her by herself, her family and her world. She struggles to trust people and is reluctant to become emotionally invested despite desiring meaningful relationships and ‘deeper connection’, believing that such relationships place her in a vulnerable position from which she may experience harm or abandonment. A also struggles to gain autonomy and individuality, especially one different from that expected of her by her mother ‘a good Christian’ – church as an extension of her mother. Although she seeks her mother’s approval and acceptance, instead she experiences criticism and rejection which reinforce her core belief. A is repeatedly confronted with the question of who she is expected to be and who she wants to be which leave her immobilised with a core belief that she is ‘not good enough’ and ‘doing the wrong thing’. A demonstrates anxious and perfectionistic traits with neurotic personality organisation in an attempt to please her mother and meet her expectations. Despite her many strengths, A fundamentally feels inadequate and incompetent. In the struggle to individuate from her mother, A is neither alone or abnormal, for a key developmental task of late adolescence and early adulthood is to shape a new sense of self – Identity versus Confusion in Erikson’s Stage of Development / Mahler’s separation-individuation. Conversely, it is not uncommon for this shaping of self-identity to result in family conflicts, especially in families that demand the children follow the parents’ dictates rather than their own. A may benefit from cognitive framing of her difficulties with her mother as strength rather than weakness, a sign of her autonomy and sense of self. In this respect, it may be helpful to allow A to have a more balanced perspective on her strengths and weaknesses. The objective is not to impose a particular choice on A, but rather to help her make her own choices and ultimately accept herself. A’s therapy goals will be non-ambitious and supportive. Establishing a place of safety within a therapeutic frame is of particular importance for A was unable to have such throughout her life. Over the years, A has developed defence mechanisms to cope with this distress. Through intellectualisation, humour and altruism, she is able to channel her impulses in a manner that avoids direct conflict with her family. Isolation of affect and anger turned inward serve to contain A’s feelings of unsafety and mistrust whilst preventing retaliation on the part of her abusive father and controlling mother. When these fail, A withdraws into more neurotic defences such as dissociation and repression. Such defences may have short-term advantages in coping, but can often cause long-term problems in life when used as one’s primary style of coping with the world. PATIENT SELECTION A has relevant positives and negatives which make her a suitable candidate for psychodynamic psychotherapy.As for the positives, A presents with a combination of mood and anxiety symptoms secondary to interpersonal and characterological difficulties rooted in developmental and traumatic issues that would benefit from more than brief psychotherapy. She is motivated to understand herself and develop her own sense of self. She is interested in a deeper understanding of where her difficulties arise from and does not seek rapid amelioration of her symptoms or concrete guidance in her life. She demonstrates psychological mindedness with the ability to reflect, free-associate and think metaphorically. She has a sense of humour and caring nature. As for the negatives, A does not have significant substance, forensic or medicolegal history. She has low levels of acting out and no evidence of psychopathy. Despite her psychiatric admission for treatment of reactive psychosis, A has remained well with no evidence of psychosis since discharge. PSYCHOTHERAPEUTIC PROCESSESThe sessions are conducted in a clinic room at the community health centre for 1 hour every week. They end at the same time even if A attends late. The first five sessions were used for assessment, initial formulation and suitability. The subsequent sessions were largely used to explore her views on religion, relationships and family, while normalising her difficulties. Psychoeducation was provided on themes including the window of tolerance, grounding techniques and pros & cons model. She responds well to metaphors, such as ‘looking for breadcrumbs when I should be looking for a whole loaf’. Some of the challenges during this work include transference and countertransference difficulties. A may perceive the therapist as a critical figure just like her mother and misinterpret the comments as invalidating. A also initially appeared reluctant to disclose her thoughts and feelings in an attempt to avoid potential harm. However care needs to be taken to avoid becoming overprotective, directive or crossing boundaries. There have been moments of boundary crossing during the course of therapy to date, such as A asking the therapist personal questions or for clinical duties that are outside the scope of psychodynamic psychotherapies. These boundary crossings are understood as A’s need for connection and redirected gently. RISK ASSESSMENT AND MANAGEMENTA has a history of deliberate self-harm by superficial cutting during her teens but not requiring medical attention or recent episodes. She has no history of suicide attempts or aggression. She does however have difficulties in identifying unsafe or unhelpful relationships, and coping with losses. These can act as destabilisers during the psychotherapeutic treatment. She reported engaging in more risky sexual activities following a recent relationship breakdown in more recent sessions. Psychoeducation on establishing physical and mental safety was provided while the EIPS case manager was notified for closer monitoring. MEDICAL TREATMENTDuring her psychiatric admission, A underwent first episode psychosis work-up including bloods, EEG and MRI brain which were unremarkable. After discharge, A underwent pharmacogenomics testing due to hypersensitivity to medications and vulnerability to side effects. She was subsequently reviewed by a geneticist who recommended that she is on the smallest number and lowest dose of psychotropic medications possible. The implication of this was that her management had more weighting on non-pharmacological approaches including psychotherapy. NOTE KEEPINGEach session is voice recorded and briefly entered on electronic medical records with the main themes of the therapy, risks identified and plan. The voice recording is then transcribed. Detailed notes are de-identified and stored electronically in a personal USB. The transcription and detailed notes are used for discussion during supervision.
ST is a 58 year old unemployed married Lebanese-Australian male who presented for evaluation and treatment for chronic depressed mood since his divorce XY years ago. Since then, he also noted anhedonia, apathy and insomnia with recurrent episodes of irritability and
ST appears to meet criteria for
ST has difficulties particularly with facing situations involving uncertainty and perceived lack of control.
Last modified: Wed Mar 19 17:03:41 2025