Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_205_библиотеки_им_акад_М_И_Перельмана
.pdf
442 The APA Publishing Textbook of Mood Disorders, Second Edition
https://t.me/med1917
Weissman MM, Markowitz JC, Klerman GL: The Guide to Interpersonal Psychotherapy. New
York, Oxford University Press, 2018
Wells KB, Stewart A, Hays RD, et al: The functioning and well-being of depressed patients.
Results from the Medical Outcomes Study. JAMA 262(7):914–919, 1989 2754791
Wilfley DE, MacKenzie RK, Welch RR, et al: Interpersonal Psychotherapy for Group. New
York, Basic Books, 2000
Zlotnick C, Johnson SL, Miller IW, et al: Postpartum depression in women receiving public
assistance: pilot study of an interpersonal-therapy-oriented group intervention. Am J Psy
chiatry 158(4):638–640, 2001 11282702
-
CHAPTER 25
https://t.me/med1917
Psychoanalytic
and Psychodynamic
Psychotherapy
for Depressive Disorders
Glen O. Gabbard, M.D.
The terms psychoanalytic and psychodynamic are often used
interchangeably because both terms refer to a set of principles that have grown out of
psychoanalytic writing and research over a period of more than 100 years. The basic
ideas that are included in these principles include the following (Gabbard 2014):
1. Much of mental life is unconscious.
2. What is unique and highly subjective about the patient provides a pathway to un-
derstanding the patient.
3. Symptoms of behavior are external manifestations of unconscious processes, often
referred to as psychic determinism.
4. Past is prologue, meaning that early developmental experiences create unique
qualities in each individual.
5. The patient experiences the doctor as a significant figure from the patient’s past, a
clinical phenomenon known as transference.
6. Doctors, like patients, may reexperience the patient according to relationship pat-
terns that have been internalized by the doctor, a concept known as countertrans-
ference.
7. Patients tend to resist the help of the doctor because they are conflicted about
change and about sharing their inner world with another human being, a principle of psychodynamic and psychoanalytic thinking referred to as resistance.
443
444 The APA Publishing Textbook of Mood Disorders, Second Edition
https://t.me/med1917
Both psychoanalytic and psychodynamic treatments are based on these foregoing
principles. The two terms are often used interchangeably when applied to psycho
therapeutic treatments. Both are making an effort to see how the past is repeating itself in the present to identify unconscious forces at work, and to carefully observe
how the patient is resisting the help that is offered. The term “psychoanalytic” often
implies a more intensive approach consisting of three to five sessions per week. It is
sometimes, but not always, carried out with the patient lying on the analyst’s couch
instead of sitting up. Psychodynamic psychotherapy is generally conducted once or
twice a week with the patient sitting up.
Psychodynamic Understanding of Depression
and Dysthymia
Psychoanalysts and psychodynamic therapists have postulated a number of themes
in depressed patients that help the clinician focus on the specific factors that contrib
ute to depression and dysthymia in each individual patient. This chapter is designed
to discuss psychodynamic therapy with both major depressive disorder and persistent
depressive disorder (dysthymia). The psychodynamic approach is highly similar
with the two conditions, and both involve the principles of adjusting the therapist’s
interventions to the patient’s capacity to use them. While dysthymia is considered to
be a more chronic form of major depressive disorder (MDD) that often involves persisting characterological themes, recurrent MDD may also have chronic elements and
aspects that reflect personality pathology.
In Freud’s original contributions (Freud 1917/1963), he suggested that early losses
in childhood lead to vulnerability to depression in adulthood. He also noted that the
marked self-deprecation commonly found in depressed patients often relates to anger
turned inward. Freud noted that internalizing a lost object (person) and identifying
with it may be the only way that some people can give up an important figure in their
life. He also noted that depressed patients often suffer from a severe superego or conscience, which he related to their guilt for having shown aggression toward loved
ones.
Edward Bibring (1953) had substantial differences from those of Freud regarding
the role of aggression. He believed that depression was better understood as a pri
mary affective state unrelated to the “aggression turned inward” notion that Freud
emphasized. He thought that depression arose from the tension between ideals and
reality. He noted three highly invested aspirations—to be worthy and loved, to be
strong or superior, and to be good and loving, all rather strict standards of conduct.
The patient’s awareness of his or her inability to live up to those standards produced
depression in Bibring’s view. As a result, the depressed person would feel powerless
and helpless. He noted that wounds to the person’s self-esteem might precipitate a
clinical depression. He did not think a harsh conscience/superego had a major role in
the process.
Edith Jacobson (1971) built on Freud’s formulation by suggesting that depressed
patients actually behave as though they are the worthless, lost love object, even
though they do not assume all the characteristics of that lost person. Eventually this
lost external love object is transformed into a sadistic superego. A depressed patient
-
-
-
Psychoanalytic and Psychodynamic Psychotherapy for Depressive Disorders 445
https://t.me/med1917
then becomes “a victim of the superego, as helpless and powerless as a small child
who is tortured by his
Arieti (1977) postulated a preexisting ideology in persons who become severely
depressed. He noted that such patients often have a pattern of living for someone else
instead of for themselves. He termed the person for whom they live the dominant other.
The spouse is often the dominant other in this formulation, but sometimes an ideal or
an organization can serve the same function. Arieti used the term dominant goal or
dominant etiology for a transcendent purpose or aim that occupies this space in the in
dividual’s psychological world. These individuals may feel that living for someone
or something else is not working out for them, but they feel unable to change. They
may believe that life is worthless if they cannot elicit the response they wish from the
dominant other or if they cannot achieve their impossible goal.
Almost all psychoanalytic and psychodynamic views emphasize a fundamental
narcissistic vulnerability or fragile self-esteem in depressed patients (Busch et al.
2004). Aggression and anger also are implicated in most theories, particularly in connection with the guilt and self-denigration that they produce. In addition, depression
is often accompanied by the seeking out of a highly idealized caretaking figure, even
though there may be a certainty that one will not find such a person. This paradoxical
search for someone that may not really exist is often a part of the depressive feature.
A critical superego appears to play a central role in this configuration of depression
and often becomes tormenting in its demands on the individual.
More recent contributions on the etiology of depression and dysthymia incorporate genetic and biological factors that have been shown to be of great importance in
understanding depressive illness. Indeed, depressive illness serves as an ideal model
to study how genes and environment interact to produce clinical syndromes. We now
understand the etiology of unipolar depression as approximately 40% genetic and
60% environmental (Nemeroff 2003).
Kendler et al. (1995) gained significant insight into the etiology of depression by
using data from an expanded sample of a twin study. The most compelling model
that emerged from the findings was one in which sensitivity to the depression-inducing effects of stressful life events appeared to be under genetic control. For example,
when the individuals who had the lowest genetic risk for MDD were examined, they
had a probability of onset of MDD per month of only about 0.5% in the absence of a
stressful life event. When these individuals were exposed to a stressor, however, the
probability went up to 6.2%. In those individuals who were at the highest genetic risk,
the probability of onset of depression per month was only 1.1% without exposure to
a life stressor, but the risk rose dramatically to 14.6% when a stressful life event was
present.
In a subsequent analysis of his data, Kendler et al. (1999) found that the most powerful stressors appeared to be death of a close relative, assault, serious marital problems, and divorce/breakup. However, there is also considerable evidence that early
experiences of abuse, neglect, or separation may create a neurobiological sensitivity
that predisposes individuals to respond to stressors in adulthood by developing a
major depressive episode. In their later work, Kendler et al. (2001) found that men
were more sensitive to the depressogenic effects of divorce/separation and work
problems, whereas women were more sensitive to the depressogenic effects of problems encountered with individuals in their proximal network.
cruel, powerful mother” (p. 252).
-
446 The APA Publishing Textbook of Mood Disorders, Second Edition
https://t.me/med1917
Freud’s view that early loss created a vulnerability to predispose one to depression
in adulthood has been confirmed by recent research. Agid et al. (1999) reported a casecontrol study in which rates of early parental loss due to parental death or permanent
separation before the age of 17 years were evaluated in patients with various adult
psychiatric disorders. Loss of a parent during childhood significantly increased the
likelihood of developing MDD during adult life. The effect of loss due to permanent
separation was more striking than the effect of loss due to death, as was the effect of
loss before the age of 9 years compared with loss in later childhood or in adolescence.
Both physical and sexual abuse have been independently associated with adult
depression in women. Women with a history of childhood abuse or neglect are twice
as likely as those without such a history to have negative relationships and low selfesteem in adulthood (Bifulco et al. 1998). Those neglected or abused women who
have the negative relationships and low self-esteem in adulthood are then 10 times
more likely to experience depression.
Heim et al. (2000) studied 49 healthy women ages 18–45 years who were taking no
hormonal or psychotropic medications. They divided the participants into four
groups: 1) those with no history of childhood abuse or psychiatric disorders, 2) those
with current MDD who were sexually or physically abused as children, 3) those with
out current MDD who were sexually or physically abused as children, and 4) those
with current MDD but no history of childhood abuse. Those women in the study with
a history of childhood abuse exhibited increased pituitary, adrenal, and autonomic responses to stress compared with control subjects. This was particularly significant in
women with current symptoms of depression and anxiety. The adrenocorticotropic
hormone response to stress in women with a history of childhood abuse and a current
MDD diagnosis was more than sixfold greater than the response of age-matched control subjects. The investigators concluded that hypothalamic-pituitary-adrenal axis
and autonomic nervous system hyperreactivity related to corticotropin-releasing hor
mone hyposecretion as a persistent consequence of childhood abuse may contribute
to the diathesis for adult depression.
More recent research (Munjiza et al. 2018) has suggested that a higher concentration of interleukin-6 (IL-6) may be a possible link between MDD and childhood abuse.
In a study of 64 depressed patients and 53 healthy control participants matched for age
and gender, the concentration of IL-6 was significantly higher in patients with MDD
than in healthy controls. Moreover, the total score on the Childhood Trauma Questionnaire was highly correlated with IL-6 levels. Persons who had been physically abused,
physically neglected, and emotionally abused had higher levels of IL-6. Another study
(van Nierop et al. 2018) showed that altered stress reactivity after exposure to childhood trauma may be an additional factor. In this investigation, individuals exposed
to childhood trauma showed a significant increase in emotional reactivity to daily life
stress.
Stressors in childhood are inherent in a psychodynamic model that sees adult pathology as related to early traumas. However, the dynamic perspective also takes into
account the meaning of a particular stressor. Clinicians must keep in mind that what
may seem like a relatively mild stressor to an outside observer may have powerful conscious or unconscious meanings to the patient that greatly amplify its impact. Hammen (1995) noted that “the field has reached considerable consensus that it is not the
-
-
Psychoanalytic and Psychodynamic Psychotherapy for Depressive Disorders 447
https://t.me/med1917
mere occurrence of the negative life event, but rather the person’s interpretation of the
meaning of the event and its significance in the context of its occurrence” (p. 98). Kendler et al. (2003) suggested that life events with particular meanings to the individual
may be more closely linked to the onset of MDD in adult patients. In interviews with
his twin sample, Kendler’s investigation team found that onset of MDD was predicted
by higher ratings of loss and humiliation among the stressors. They also noted that
events with a combination of humiliation (because of a separation initiated by a signif
icant other) and loss were more depressogenic than pure loss events such as death.
Humiliating events that directly devalued the individual in a core role were strongly
linked to the risk for a depressive episode. Psychodynamic therapists explore the
meaning of all stressors to determine the unique way that these stressors affected the
patient.
A psychodynamic psychotherapist would understand that a model of depression
that is most useful to the clinician incorporates early experiences of trauma that lead
the child to develop a problematic representation of self and other. In the case of physical and sexual abuse, the child internalizes a bad self deserving of abuse that feels
hypervigilant about victimization. The representation of others is likely to be that of
an abusive punitive figure that attacks the self. The feeling of being tormented or persecuted by this abusive internal object fits well with observations of a punitive superego. Similarly, early loss of a parent leads a child to develop a sense of an abandoned
self that cannot have its needs met in the usual way by a parent. The child also inter
nalizes an abandoned representation of others and grows up with a sense of loss and
longing that becomes reactivated with any adult stressor involving loss. Hence the
effects of losses are magnified when they occur in adult life. Because child self-esteem
is largely based on how the child is treated in early family interactions, a vulnerable
self-esteem is also a legacy of childhood loss and trauma. Adults with this back
ground may have difficulties forming and maintaining relationships and be more
vulnerable to loss and narcissistic injury from others.
Another principle of psychodynamic thinking is to focus on what is unique about
each patient as opposed to seeing patients as part of one large group. Psychodynamic
models of depression take into account unique qualities of defense mechanisms and
object relations in each depressed person. For example, Blatt (2004) studied large populations of depressed patients and noted that two underlying psychodynamic types
emerged in his populations. Anaclitic-type depressed patients are characterized by
feelings of helplessness, loneliness, and weakness related to chronic features of being
abandoned and unprotected. These individuals have longings to be nurtured, protected, and loved. They are characterized by vulnerability to disruptions of interpersonal relationships, and they typically use defense mechanisms of denial, disavowal,
displacement, and repression. By contrast, introjective-type patients are primarily concerned with self-development. Intimate relationships are viewed as secondary, and
these individuals use different defense mechanisms, namely intellectualization, reaction formation, and rationalization. They tend to be perfectionistic and competitive
and are excessively driven to achieve in school and in work. While individuals with
the anaclitic type manifest their depression primarily in dysphoric feelings of abandonment, loss, and loneliness, those with the introjective type manifest their depression in feelings of guilt and worthlessness.
-
-
-
448 The APA Publishing Textbook of Mood Disorders, Second Edition
https://t.me/med1917
Outcome Studies
Meta-analyses focused on short-term psychodynamic psychotherapy (usually consisting of 16–24 weekly sessions) have confirmed the efficacy of psychodynamic psychotherapy for the treatment of depression. A meta-analysis by Driessen et al. (2010)
included 23 studies totaling 1,365 subjects. Short-term psychodynamic psychother
apy was found to be significantly more effective than control conditions, and the
changes from pretreatment to posttreatment were large and maintained in follow-ups
1 year later. When short-term psychodynamic therapy was compared with other psy
chotherapies, no significant differences were found at 3-month or 12-month followups. Those treatments that focused more on the supportive end of the continuum
were equally as effective as those that were more expressive and focused.
Driessen et al. (2013) more recently compared the efficacy of psychodynamic psychotherapy with that of cognitive-behavioral therapy (CBT) in a randomized controlled
trial involving 341 outpatients seeking treatment for MDD, making it the largest ran
domized controlled trial of dynamic psychotherapy conducted to date. Each group received 16 sessions of treatment. No statistically significant treatment differences were
found for any of the outcome measures. The average posttreatment remission rate was
22.7%. The key finding was that psychodynamic psychotherapy was not inferior to CBT.
Cuijpers et al. (2008) conducted seven meta-analyses involving a total of 53 studies
in which seven major types of psychotherapy for mild to moderate adult depression
were directly compared with one another. Each major type of treatment had been examined in at least five randomized controlled trials, and psychodynamic psychotherapy was one of the treatments considered. The investigators found no evidence that
any one of the treatments was more or less efficacious than another, with the exception
of interpersonal therapy (somewhat more efficacious) and nondirective supportive
treatment (somewhat less efficacious). They concluded that there were no large differences in efficacy among the major psychotherapies for mild to moderate depression.
A randomized controlled pilot investigation (Gibbons et al. 2012) found that shortterm dynamic psychotherapy is effective for depression in a community mental
health system. Forty treatment-seeking patients with moderate-to-severe depression
were randomly assigned to receive twelve weeks of psychotherapy with either a community therapist trained in brief dynamic psychotherapy or a therapist providing
treatment as usual (TAU). When the results were examined, it was determined that
blind judges were able to discriminate the dynamic sessions from the TAU sessions
on adherence to dynamic interventions. Moreover, although this pilot study did not
have adequate statistical power to assess efficacy, moderate to large effect sizes for
dynamic psychotherapy over TAU were noted: 50% of patients treated with dynamic
therapy moved into a normative range on depressive symptoms compared with only
29% of patients treated with TAU.
This pilot study by Gibbons and colleagues was followed by a randomized clinical
noninferiority trial in 2016 that directly compared cognitive therapy with dynamic
therapy for treating MDD in a community mental health setting (Gibbons et al. 2016).
The trial included 237 adults. The authors concluded that when intensive expert supervision is used in community mental health settings, dynamic therapy is not inferior to cognitive therapy on change in depression for the treatment of MDD.
-
-
-
Psychoanalytic and Psychodynamic Psychotherapy for Depressive Disorders 449
https://t.me/med1917
The empirical data from randomized controlled trials focus on the less severe cases
of depression, for which dynamic therapy has been shown to be efficacious. Much
less is known about moderate to severe depression. A recently published pilot study
(Fonagy et al. 2020) made an effort to evaluate the efficacy of treatment with more severely disturbed depressed patients. The 147 patients in the study were randomly assigned to receive one of three treatments: CBT, a control intervention, and dynamic
interpersonal therapy (DIT). Sixteen sessions of treatment were delivered over a 5
month period. DIT is a psychodynamic treatment for depression that includes mentalization-based treatment. Patients whose symptoms meet criteria for MDD of a
moderate to severe nature were assessed at baseline, 3 months, and 6 months using
several measures. Patients who received DIT and those who received CBT showed
equivalence on most outcomes. Moreover, they did better than patients who received
the control intervention. The authors concluded that DIT was effective in a primary
care setting at a comparable level to CBT, and was much more effective than a control
condition. Further research is needed to clarify the role of DIT.
Despite the optimism for the efficacy of short-term treatment for depression, some
concern has arisen. When short-term dynamic psychotherapy of 16 sessions or so is
used for depression, a significant number of depressed patients do not respond adequately within this time frame. A randomized controlled trial investigating the effectiveness of long-term psychoanalytic psychotherapy (LTPP) compared that treatment
approach with TAU for individuals diagnosed with treatment-resistant depression
(Rost et al. 2019). Patients were rated over an 18-month treatment period and a 2-year
follow-up. As expected, depressed patients with more maladaptive dependence and
self-critical features did not benefit from LTPP or TAU. Patients with less maladaptive
self-critical features benefited from both LTPP and TAU, while those with more maladaptive dependent features showed considerable gains from LTPP but not from
TAU, with medium to large effect sizes. The authors concluded that clinicians need to
modify and tailor treatment in accordance with the individual pretreatment personality features.
In this section on outcome studies, the reader will note that there are no controlled
studies of bipolar depression using psychodynamic psychotherapy techniques. Bipo
lar illness is biologically driven to a great extent and does not tend to respond to psychodynamic techniques. Insight is generally absent in patients who are in the midst of
a manic episode. However, having clarified this issue, clinicians treating bipolar pa
tients can carefully note the connections between specific life events and relapse as part
of the ongoing monitoring. Moreover, treaters can help their bipolar patients recognize
the psychic discontinuity characteristic of the illness. In other words, the version of the
self that appears during a manic episode may be viewed as entirely disconnected from
the self in the euthymic phase. Clinicians can work with the patient to piece together
the fragments of the self such that the patient has a more continuous narrative of his or
her life (Gabbard 2014).
-
-
-
Implementing the Psychotherapy
The first step in psychotherapy of depression is establishing a therapeutic alliance. In
a recent meta-analysis involving 200 research reports and more than 14,000 treat-
450 The APA Publishing Textbook of Mood Disorders, Second Edition
https://t.me/med1917
ments, Flückiger et al. (2012) found that there is a robust correlation between the therapeutic alliance and positive outcome. The link is present regardless of whether
disorder-specific manuals are used and regardless of the type of psychotherapy or the
specificity of outcomes. Hence the therapist needs to make an effort to forge a positive
alliance as the first order of business in psychotherapy of depression. Therapists
should not judge or try to cheer up the patient as others do. They also should accept
the notion that there are reasons to be depressed. Unlike others in the patient’s family,
they do not exhort the patient to snap out of it. A dynamic therapist will collaborate
with the patient on a pursuit of possible factors that have contributed. The depressed
individual has already heard others saying that there is no reason for depression, and
the therapist must operate from the assumption that from the patient’s vantage point,
there is something to be depressed about. Empathy and active listening are far more
important than interpreting or trying to talk the patient out of the demoralizing state.
As therapists listen to their patients tell their stories, they carefully evaluate the nature of stressors that may have triggered the depression. The therapist would want to
know if the stressor involved loss and humiliation or if it reawakened early childhood
losses or traumas. Meaning is an essential part of the psychodynamic exploration.
Whatever the stressor was, the therapist wants to know about the meaning of that
ings or thoughts from the past? In many ways, the key to the establishment of a therapeutic alliance is for the therapist to pursue the “person” rather than trying to eradicate
the “illness.” Although it may sound counterintuitive, forming a bond with the patient
and consistently trying to understand what is going on, with or without concurrent
medication, may be the key to helping the patient.
Another approach that may serve to build a therapeutic alliance is a frank discussion
about what psychotherapy is and what it is not. Therapists may also need to explain
that much of mental life is unconscious and that problematic patterns in the patient’s
life are likely caused by factors that are not completely within the conscious awareness
of the patient. The collaborative nature of therapy should also be spelled out (Gabbard
2017). Astudy by Goldman et al. (2013) found that psychodynamic therapists who are
more collaborative in identifying specific goals and explicitly defining the focus of the
treatment, as well as providing a clear rationale for their model, may facilitate a
strong therapeutic alliance.
As the therapist continues to listen to the patient’s story, questions about suicide
can be gently introduced. If suicidal fantasies are present, the therapist wants to know
what part of the patient or the patient’s life is so horrific that suicide is the only answer. As the stressors are evaluated, a psychodynamic therapist listens closely to the
themes that occur around relationship patterns and the rise and fall of the patient’s
self-esteem. Is the patient concerned about destructiveness or greed that may have
harmed loved ones? Is the patient harboring a perfectionistic view of the self that
seems out of reach? Has anger been turned inward, and is the patient tormented by a
harsh superego or conscience that is constantly expecting more of the patient? Have
there been significant losses recently that the patient feels are irreparable? What defense mechanisms seem to be prominent in the patient’s efforts to manage the painful
emotional state?
As the psychotherapist understands more about the patient, she may join the patient in trying to conceive new ways of living with different aspirations, perhaps not
-
Psychoanalytic and Psychodynamic Psychotherapy for Depressive Disorders 451
https://t.me/med1917
so idealized, and more realistic goals and objectives. Therapists must be patient and
avoid rushing to tell patients what their goals should be. It is usually more useful to
wait for the patient to articulate his or her goals so that they are “owned” by the pa
tient. In the long run, it is best for the patient to struggle with the complex issues he
is confronting as the therapist helps to articulate to the patient particular meanings
that may be attached to his suffering.
While relational issues and interpersonal meaning are almost always connected to
a depression, patients often do not want to discuss those interpersonal implications.
They often prefer the notion that depression and suicidal wishes arise out of nowhere
rather than seeing them as having emerged from significant relational conflicts. Even
though some of the factors leading to the depression may be unconscious, careful at
tention to transference and countertransference developments may lead to further
understanding about the patient’s resistance to therapy or to change.
Common countertransference dilemmas occur in the psychotherapist of the depressed patient. These may include feelings of despair and hopelessness, anger that
the patient does not get better more quickly, wishes to transfer the patient to another
therapist, powerful rescue fantasies, and a host of other feelings that depend on the
fit between therapist and patient. An impasse may arise between patient and therapist, and it is an opportunity for both therapist and patient to constructively collaborate on figuring out what is being recreated in the transference-countertransference.
Psychodynamic therapy is sometimes referred to as expressive-supportive psycho-
therapy (Gabbard 2017). On the expressive end of the continuum are comments that
may be more challenging to the patient: interpretation of unconscious meanings, ob
servations about aspects of the patient that are not in the patient’s awareness, confrontations that are designed to make the patient aware of aspects of her character that may
not be in her awareness, and clarifications that involve an effort to help the patient be
clearer about what she may be trying to communicate. On the supportive end of the
continuum are the following interventions: empathic validation of the patient’s experience and feelings, psychoeducational interventions that are designed to inform the
patient about aspects of depression or of the treatment literature, and advice and
praise, both of which provide support to the patient who is highly self-critical and selfdoubting. In a middle position, which is neither expressive nor supportive, one would
find an intervention known as encouragement to elaborate. This type of comment may be
as simple as “Tell me more about that” or “What comes to mind about that?” The goal
is to help the patient describe a situation more fully. Throughout psychodynamic therapy, the therapist must adjust the interventions to the patient’s capacity to tolerate
them at a particular moment in the treatment. Hence the therapist moves back and
forth along the continuum based on the patient’s readiness to hear and contemplate
what the therapist is saying.
Concerns about suicide must be repeatedly evaluated in the course of the therapy.
Patients may wish to hide such feelings from the therapist, so an atmosphere must be
created by the therapist such that suicidal ideas and wishes can be spoken about
frankly with the therapist, who must not respond with dismay. Patients must be encouraged to articulate what they think that suicide would accomplish and how others
might be affected by it.
A psychodynamic therapist must operate within a biopsychosocial perspective.
While the therapist is trying to help a patient understand what depression is and
-
-
-
Соседние файлы в папке Библиотека им академика М.И. Перельмана