Maximizing Supervision Finding the Most Suitable Therapeutic Approach

Having learned much from her first supervisor, a psychodynamic sage, Jenna was eager to begin studying with her second supervisor, known for his knowledge of cognitive techniques. When her first client, a depressed male graduate student, scored in the narcissistic range on the MCMI-III, her new supervisor recommended that she educate the client in the principles of cognitive therapy, focusing particularly on the discovery of automatic thoughts and their connection with his self-image, which featured quickly vacillating appraisals of his ability, ranging from godlike to pathetically inadequate. After the first two sessions, however, she noticed that the client seemed increasingly condescending, apparently chaffed by her attempts. Realizing that the personality disorder was the most important factor driving his depression, Jenna suggested to her new supervisor that perhaps the automatic thoughts underlying the transference itself could be discussed as a means of synergizing the psychodynamic, interpersonal, and cognitive approaches. By allowing therapy to temporarily refocus on the exploration of the narcissistic self, the client's mood lifted and the discovery of automatic thoughts proceeded more quickly. Thus led to the edge of insight, the client soon discovered that the transference relationship formed an instructive microcosm of his relationships outside the therapy office.

in relationships? What cognitive distortions perpetuate maladaptive appraisals of personal and social realities? And so on.

Diagnostic labels assist somewhat in answering these questions, but are rarely definitive. By allowing multiple secondary diagnoses, even the DSM-IV recognizes that an antisocial-narcissist overflows what is merely an antisocial or that a dependent-avoidant overflows what is merely a dependent. Most individuals, in fact, combine aspects of two or more personality disorders. Because each personality disorder is strongly associated with certain defense mechanisms, with a particular cognitive style, with certain interpersonal attitudes, and so on, these prototypal features become hypotheses for the individual case that can be checked against the actual assessment data. Narcissists, for example, tend to rationalize; they look at their conduct after the fact and try to imagine how it might be made reasonable. This suggests that your narcissistic patient probably does the same thing, a hypothesis that can be checked against other information or in therapy itself. However, if the subject is diagnosed as a narcissistic-dependent, this suggests that dependent features infiltrate the primary diagnosis. Rather than rationalize, dependents tend to introject, strengthening bonds with caretakers in order to co-opt their instrumentalities in the real world. Most individuals do, in fact, combine aspects of two or more personalities, creating assessment and therapy cases that are naturally complex. Does the narcissistic-dependent lean more toward rationalization or introjection? If both, which is preferred in what kind of situation? Considering such questions takes the assessment far beyond mere diagnostic labels, falsifying the classification system while building idiographic validity. And this is exactly how it should be. Clinicians do not treat prototypes; they treat persons.

Belief Change 101

Belief Change 101

Do you suffer from a habit or a behavior or a repetitive thought pattern that keeps you from being who you want to be? Do you try to change this or that aspect of your life, but wind up right back where you started? You're not alone! Millions of Americans try to make changes, but the whopping majority fail exceptionally.

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