Managing treatment Starting treatment

Establishing parameters

Most psychodynamic therapists, explicitly or implicitly, convey objectives and expectations to their patients. The details of this agreement normally include arrangements for a time and a place as well as the length and frequency of sessions. Usually a tentative idea is offered as to the likely duration of therapy: 'It is likely to take years rather than months'. Most therapists also describe the expected behaviour of the patient and the therapist: 'I would like you to be as open and honest with me as possible and say absolutely everything that comes into your mind. This is the fundamental rule'. In fact it is very likely, in view of the variety of such agreements that tend to be made, that its emotional context is more relevant than the specific items agreed upon. Such a 'contract' implies recognition by both patient and therapist that the process of therapy needs protecting and that it is important enough to require a sacrifice from both parties.

In the treatment of severe personality disorders, contracts may have an additional important function—that of protecting the therapy from incessant enactments, self-harming, parasuicidal gestures, and so on. In Kernberg's approach to the treatment of borderline patients, the patient formally undertakes not to seek the therapist's help outside of office hours, not to engage in acts of violence, and to deal with self-destructive acts through normal medical channels. (60) Whilst such agreements are commonly made in long-term therapy, it is by no means clear that they are either essential or useful.

Formulation of patients' problems

An important part of initiating any psychosocial treatment is arriving at least at a preliminary formulation of the patient's problems. In the case of psychodynamic therapies this represents a special challenge because of the diversity of the possible theories to draw on. In principal, psychodynamic formulations would identify key unconscious conflicts, central maladaptive defences, unhelpful unconscious fantasies and expectations, deficits in personal development, and so on. The complexity of such formulations is such that agreements are hard to arrive at even when clinicians follow similar orientations. In the absence of a generally accepted format for formulating the patient's problems, a list of key parameters may be offered:

1. the maturity of relationship representations (three or more persons versus just a self-other dimension);

2. the maturity of psychic defences;

3. the extent of whole as opposed to part object relations (e.g. whether a person is represented as performing more than a single function for the patient);

4. the general mutuality of the relationship patterns described—the quality of attachment to others.

It should be noted that psychodynamic formulations tend to change as treatment progresses. Indeed, Winnicott described psychoanalysis as 'an extended form of history taking'/61

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