Indications contraindications and selection procedures

Medical treatments normally have indications and contraindications. In psychodynamic treatment the term 'suitability' indicates a looser notion of the appropriateness of the approach.(48) Nevertheless, based primarily on clinical experience, some writers have arrived at specific criteria for long-term psychodynamic therapy. (49> Some authors have also suggested relatively systematic methods of assessment yielding both diagnostic and prognostic information. (50) The majority of psychodynamic clinicians, however, rely on clinical judgements based on interpersonal aspects of their first meeting with the patient. (39> The three areas of assessment are personal history, the content of the interview, and the style of the presentation.

A history of one good relationship has been traditionally regarded as a good indicator. (5!> By contrast, a history of psychotic breakdown, severe obsessional states, somatization, and lack of frustration tolerance are generally considered contraindications. However, increasingly, as 'easy' patients are referred for briefer therapies, long-term psychodynamic therapy has come to be seen as a therapy of last resort. There are case reports of successful treatments of individuals with psychosis, (52) mental retardation/53,' and chronically poorly controlled diabetic patients.(54)

The content of interviews is harder to judge. In general, the presence of some kind of 'mutuality' between therapist and patient is a positive indicator. Some clinicians offer 'trial interpretations' which summarize their initial impressions, and a positive thoughtful response to these is regarded a good indication. The capacity to respond emotionally within the assessment session is a further indicator.(55) Motivation for treatment is harder to ascertain. Most patients express enthusiasm for the treatment, which falls away once they are asked to confront unpleasant or unflattering parts of themselves.

More recently, psychodynamic therapists have given increasing consideration to the style of the patient's discourse during assessment rather than its content. For example, Holmes(56) attempts to identify whether patients' narrative styles are avoidant (sparse and dismissing of interpersonal issues) or enmeshed and entangled (excessive current anger about past hurts and insults). There is one study with findings which indicate that, in a severely personality disordered population at least, the avoidant type of patient has a better prognosis in psychodynamic therapy. (57> A further relevant capacity often reflected in narrative has been variously described as seeing oneself from the outside,(58) reflecting on one's inner world, (49> or having fluidity of thought. (59>

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