Transference Module Psychiatric Training

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1 Transference Module Psychiatric Training Iram Shah Highly Specialist Psychotherapist Forensic Psychology Roseberry Park and HMP Low Newton Trauma Service

2 Freud's concept of transference was not the discovery of a solitary genius, but was an inspired, creative synthesis deeply rooted in the prevailing discourses of his time. In the nineteenth century, transference started out as a neurologic term. Freud used the concept of displaceable energies as the precursor to transference as we know it now in his neurologic writings as early as By 1900, transference was ready to stand, as it does today, at the core of psychoanalytic theory.

3 In Psychodynamic thinking, transference is the term given to the feelings that are projected, or transferred, from the client onto the therapist. We must be prepared to find, therefore, that the patient yields to the compulsion to repeat, which now replaces the impulsion to remember, not only in his personal attitude to his doctor but also in every other activity and relationship which may occupy his life at the time - if, for instance, he falls in love or undertakes a task or starts an enterprise during the treatment. (Sigmund Freud: Remembering. Repeating and Working-Through )

4 Object Relations Theory Psychopathology is viewed as a disturbance in the make up of the self Symptoms, mood changes, distorted perceptions of the world are all construed in terms of one s object relationships and how they ve been internalised Nature of difficulties can be traced to arrests in in development of self and anomalies in splitting

5 splitting Rooted in psychoanalytical theory Occurs in people who experience disturbed selfmother relationships during infant and early childhood development Specifically in the early development in infancy of self as individual, autonomous and separate from mother

6 Consequences Of Failure To Negotiate The Separation Individuation Stage Poor ego development Lacks integrated sense of self Poor self esteem Inner anger and feelings of frustration Poor impulse control Low frustration tolerance Impaired reality testing when stressed

7 Projective idenitification A psychological process related to splitting Attempts by patients to rid self or part of self through by projecting on to an external object - staff members The person has conflicting parental images and attempts to resolve their anxiety by projecting them onto the environment Thus we see the notion of good and bad being ascribed to different staff

8 Projection of good The staff are treated as special Creates an in group Creates a desire of parental nurturing within staff The good mother ideal

9 Projection of bad The out group Patient will try to get good group to adopt his negative view of this group This group of staff will tend to respond in negative and punishing manner The bad frustrating mother

10 countertransference counter-transference is the term used to describe the feelings in the therapist brought about by the feelings and behaviour of the client. It could be said that transference exists to some extent in every relationship, but it is only within the context of a therapeutic setting that a therapist is able to use and interpret it in order help a client understand their feelings and behaviour

11 Products of your own personal history and unresolved conflicts and those reactions that are natural responses to both idealisation and anger the hook Unconscious reaction of the nurse to the transference of the patient The total emotional reaction of the nurse to the patient in the treatment situation

12 Transference is an important concept to understand and work with with particular patients groups. Patients diagnosed with personality disorders i.e. Borderline Personality Disorder are one of the groups where understanding of transference will help in assessing and managing risk.

13 James Masterson s Development Deficit Approach

14

15 Transference and Compulsion to Repeat What interests us most of all is naturally the relation of this compulsion to repeat to the transference and to resistance. We soon perceive that the transference is itself only a piece of repetition, and that the repetition is a transference of the forgotten past not only on to the doctor but also on to all the other aspects of the current situation

16 Action and Reaction Cycle 16 People with BPD can trigger through their actions strong reactions in professionals and these reactions can lead to the professionals acting in a way that is less helpful for the client and ultimately draining for the professional. There are 3 main ways of reacting that are typical of a professional working with someone with a BPD:

17 17 1 You feel like you need to rescue them by doing things for them or in some way giving more to them than you usually give to any other client.

18 18 Thinking that if you don't rescue them they will not be able to help themselves or get the kind of help from anyone else as they are so neglected by everyone else. This becomes stronger when they tell you that you are the only one that is there for them and you are the ideal worker.

19 19 2 Feeling annoyed with them as you have done everything they want and they still have not changed Some part of you wants to get rid of them as your client

20 20 3 Thinking and feeling that nothing you do is ever good enough for them And that you are helpless to do anything more or different

21 21 Drama triangle Persecutor Rescuer victim

22 The Compulsion to Repeat We must be prepared to find, therefore, that the patient yields to the compulsion to repeat, which now replaces the impulsion to remember, not only in his personal attitude to his doctor but also in every other activity and relationship which may occupy his life at the time (Sigmund Freud: Remembering. Repeating and Working- Through )

23 BALINT TRAINING Balint group training is a well developed method of understanding the doctor/patient relationship and learning the therapeutic possibilities of communicating skillfully with patients. Michael Balint, born in Budapest in 1896, was the son of a general practitioner. After completing psychoanalytic training in Berlin and Budapest, he emigrated to Scotland and moved to London after the War, where he worked at the Tavistock Clinic.

24 Balint was concerned with the psychological implications of general practice, and devising a method of training physicians to appreciate these implications and gain a useable understanding of the doctor/patient relationship. His method and insights are spelled out in, "The Doctor, His Patient and the Illness," a book that is said to have "changed the face of British Medicine."

25 Balint training is a weekly, usually hour-long meeting of physicians, coordinated by a trained leader. The participants bring problem cases for discussion with their colleagues. Exploring these cases in depth is the principal method. The following broad categories of issues (but not limited to these) are invited for discussion: Psychological problems in the patient. Patient personality problems. Problems in the doctor/patient relationship. Problems in the family of the patient. Problems in the doctor/colleague relationship.

26 The extended group discussions create an ongoing learning environment. This process provides physicians with the opportunity to repeatedly explore and validate their perceptions of the emotional factors that play a role in illness or interfere with their successful management of the illness; to become sensitized to the effects of emotional factors and personality types on the doctor/patient relationship. The basic concept behind the need for this type of learning process is that all physicians have habitual responses to particular types of patients and problems.

27 Balint group discussion stimulates its members to examine their individual approaches and circumstances and explore alternative ways of responding. This method is not a doctor therapy group, nor is it a didactic seminar. The role of the group leader not to teach "content" or give advice, it is rather to stimulate the participants to gain a greater understanding of the doctor/patient relationship and to expand their repertoire for handling difficult situations.

28 Certain issues and clinical situations leading to an exploration of attitudes and the development of new skills include the following: Above all, the outcome of Balint training is a synthesis of cognitive and affective processing that leads the physician to a more precise, empathic and practical understanding of doctor/patient interactions and difficult patients.

29 The physician learns to be more therapeutic in his or her relationship with patients while, equally importantly, learns a framework within which to view patients and practice that leads to less frustration, dissatisfaction with practice, and burnout.

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