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The patient in crisis presents characteristically feeling overwhelmed, often confused, and needy--manifestations of their regressive experience with heightening of transference wishes. There is a sense of urgency and helplessness that impacts on a therapist's intervention. This clinical presentation frequently can evoke major countertransference responses in the therapist. An unconscious identification with the helpless, childlike patient, may lead to a variety of defensive responses, often involving fantasies of, or wishes for, omnipotent control and in some cases presenting as a grandiose rescue fantasy. Another common countertransference response is passivity, a defensive manifestation potentially lethal in the face of a seriously suicidal patient. In dealing with borderline or characterologically disturbed patients, hostile and unempathic responses are particular countertransference reactions that often represent the therapist's defensive response to the powerful, punitive and persecutory superego projections of the patient.
In the intense setting of the crisis intervention, the therapist's own unresolved conflicts also may be reactivated particularly by patients who present with similar conflicts.
In our experience we have found Milton Viederman's psychodynamic life narrative to be extremely useful in dealing with the crisis situation. Basically, this is a statement made to patients in crisis that gives their current emotional reactions meaning in the context of their life history and shows it to be a logical and inevitable product of previous life experience.
The notion of narration in psychotherapy is not new, and harkens back to Freud's early recognition that his case histories sounded more like short stories than scientific papers. In fact, Freud himself termed his mode of healing a "literary method," in which the patient was the narrator and the analyst a coauthor. In modern models of psychotherapy, this type of conceptualization has become more than a metaphor, and has especially made its appearance in the contemporary modes of cognitive and constructive psychotherapy. In his study of acts of meaning, Bruner applies the concept of a narrative to patients and nonpatients alike, proposing that all human beings are inherent storytellers, who continually construct privately developed story lines, or self-narratives, to explain themselves and their life experiences. In this paradigm, both thinking and remembering are narrative inventions that represent many possible realities. In short, each individual's narrative constitutes that person's life as he or she perceives it. Most importantly, the person's sense of self is dependent upon both the content and the cohesiveness of his or her life story. Ford and Urban make the particular point that, whereas the contents of these diverse constructs differ -- that is, the construct systems, embodied programs of action, self-construct, narrative -- the functions they are said to perform are quite similar. All are changeable with new experience, operate to create coherent organization and generalized meaning out of the flow of transient experience, and help to organize people's behavior. (p. 516)
From a therapeutic perspective, this means that the psychological understanding of a person requires, first, the identification of his or her prototypic narratives. Once this is accomplished, the therapist may help the client to coauthor a new, more adaptive life story. As the psychotherapist enlists the client as a collaborator, they can engage in the therapeutic work of, in Schafer's term, "narrative repair." The thesis here is that clients are in need of psychotherapy when their "stories" have been maladaptive because they have "broken down". Under such circumstances, narrative therapy is designed to help clients change their understanding of the past. Only then can they begin to rescript their lives in less pathological and more constructive ways.
More specifically, Viederman's psychodynamic life narrative addresses three fundamental characteristics of the patient's crisis state: 1) Psychic disequilibrium with chaos and confusion; 2) Regression with intensification of strong transference wishes; 3) The inclination to examine the trajectory of one's life as it relates to self-perception, to past accomplishments, and to future hopes and aspirations. In our setting we have modified this by focusing primarily on the recent narcissistic injury.
The psychodynamic life narrative depends to a great extent on the fundamental or primary transference, which is a substrate upon which all effective psychotherapeutic interventions rest. Patients who are capable of entering usefully into psychotherapy have developed in their life experiences, particularly in the mother/child dyad, a background of sufficient trust for the establishment of an object relationship during therapy that will enable both the therapy and the therapeutic encounter to develop.
Viederman states that the resident in the crisis situation becomes a reassuring parental figure, "[L]ike the good parent who has a perspective on the child, what is captured in the life narrative is a quality of a shared experience over time" (p. 243). This conveys to the patient a sense of hope and protection. By understanding that the regression in the patient's coping capacity and ego adaptation is representative of an earlier, more childlike mode in which the patient felt overwhelmed and helpless, we can demonstrate the sense of fluidity in the crisis situation. The patient has positive wishes for help from the resident which involve intense dependency strivings and a correlated idealization of positive parental introjects.
We as supervisors have an opportunity to use both the similar parallel and complementary dynamic in developing and clarifying the transference parameters within the supervisory process. This demonstrates the transference readiness that is apparent in the majority of crisis patients in an understandable and useful way. The important concept of the transference availability and readiness of a patient in a crisis situation is a vital component that facilitates the therapist's activity and makes it therapeutically significant for the patient. As well, in the supervisory process, the transference availability and readiness of the resident to the supervisor, based on the unconscious identification with the patient, are vital components upon which appropriate interventions can be based in both the supervisory and therapeutic relationship.
With this psychodynamic narrative focusing on the recent narcissistic injury, not only is the resident so to speak "taken in," but so is also the resident's construct. This construct is assimilated under the powerful influence of the idealizing transference that increases the ego's integrative capacity. These are important conceptualizations which come alive in the process of supervision and are useful in demonstrating to the resident an appreciation of the psychodynamic perspective in dealing with these patients. The parallel process which also readily complements the resident's own intervention with the patient is significant in the supervisory setting.
Reflection Exercise #10