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A patient had been admitted to an A & E unit after committing ‘deliberate self-harm’. He had attempted to commit suicide by overdosing on some headache tablets. When that hadn’t worked he slashed himself in several places using a kitchen knife. He arrived at the A & E unit in an extremely distressed state.
Why the psychologist was called in
Although the patient clearly had very severe physical injuries a comprehensive psychosocial assessment revealed he was suffering from severe psychological problems. His symptoms seemed to suggest clinical depression that was so deep-rooted and severe it necessitated intensive and sustained psychotherapy. Thus, it was decided to immediately refer him to a clinical psychologist. This is consistent with professional guidelines, which recommend that self-harm patients are referred for psychological intervention if an initial psychosocial assessment reveals an underlying psychological problem (NICE, 2004, p.32). A clinical psychologist is formally trained to deal with various forms of psychopathology, including clinical depression, based on psychological theories and research (Davey, 2004, pp.713-714). In addition to carrying out in-depth psychological evaluations, to identify underlying psychopathology (using a wide variety of personality and neuropsychological tests, and clinical observation), the psychologist is trained to make a formal diagnosis, using set criteria. Clinical psychologists and psychiatrists have very similar training. However a clinical psychologist rather than psychiatrist was called in to deal with this case because the latter are primarily medical doctors, and hence typically use the ‘medical model’ for dealing with psychological disorders. Psychosocial assessment suggested that this patient primarily required intensive psychotherapy rather than medication.
The clinical psychologist relied upon Sigmund Freud’s psychoanalytic theory in formulating a treatment plan (McMillan, 2001, pp.599-600). Freud’s conceptualisations have had a massive impact on popular culture, and psychology and psychiatry in particular. Psychoanalytic theory posits that unconscious conflict, often emanating from childhood, and involving forbidden sexual and aggressive desires causes psychopathology. A distinction is made between the conscious (awareness), preconscious (memories that are readily accessible), and unconscious (repressed memories of which a person may not even be aware). Superimposed against these levels of consciousness are three components of human personality: the id (basic biological drives), the ego (restrictions imposed by external reality), and superego (conscience). The id operates at the subconscious level, while the ego and superego function at the preconscious and conscious levels. Perpetual and intense conflicts between the id and the other two components can generate considerable anxiety and, if unresolved, mental health problems. Psychoanalysis places considerable emphasis on the sex drive, or ‘libido’. Humans are thought to progress through several stages of psychosexual development. Fixation at any one stage results in various emotional problems.
What the psychologist did
During the initial session with the patient the clinical psychologist immediately set up a good rapport with the patient. The priority was to assess the patients’ problem, and develop a comprehensive treatment plan with clear goals for recovery. After an initial session the patient underwent numerous sessions involving free association, a therapeutic form of psychoanalysis (McMillan, 2001, pp.167-168). During this procedure, the psychologist encouraged the patient to verbalise whatever came to mind. Free association is considered to yield clues about the subconscious roots of a patients’ problem. The patient spoke a lot about his childhood. From time to time the therapist probed with searching questions encouraging the patient to elaborate on particular statements made. During each session the psychotherapist maintained an empathic and non-judgemental demeanour, in order to facilitate a high degree of trust between himself and the patient. The patient attended weekly sessions over a six-month period. During the final month of therapy the clinician engaged in dream analysis, whereby the patient was asked to describe recent dreams in as much detail and with as much accuracy as possible.
How the psychologists’ input was assessed
By the end of therapy it had gradually become clear that the patient had been experiencing intense homosexual desires ever since puberty. These urges had been repressed for years, in order to conform to social norms and his parents’ wishes for him to get married and have children. The patient wasn’t conscious of these forbidden desires. The realisation made him feel much better, going a long way to explain why he had been feeling pathologically depressed, even suicidal. The impact of psychoanalytic therapy on this patient was assessed using a pre- and post-test experimental analysis (Coolican, 1994, pp.82-88). During his initial assessment of the patient the psychologist obtained baseline measures of psychiatric symptoms using the SCL-90-R (Derogatis, 1983), social functioning using the Social Adjustment Scale (Weissman, 1975), general adjustment in life, using the Global Assessment Scale (Endicott et al, 1976), and episodes of self-harm, using the Suicide and Self-Harm Inventory (Sansone et al, 1998) during the previous six months. At the end of therapy the therapist administered the same battery of tests to gauge any improvements in the patients’ mental health. Statistical analysis comparing pre- and post-test data, using a t-tested for repeated measures (Coolican, 1994, pp.281-286) showed significant improvements on all criteria: psychiatric functioning, and social/global adjustment, and frequency of self-harm.
Coolican, H. (1994) Research Methods and Statistics in Psychology, London, Hodder
Davey, G. (ed) (2004) Complete Psychology . London: Hodder and Stoughton
Derogatis, L.R. (1983) SCL-90-R: Administration, Scoring, and Procedures Manual, II. Towson, Md, Clinical Psychometric Research.
Endicott, J., Spitzer, R.L., Fleiss, J.L. & Cohen, J. (1976) The Global Assessment Scale: a procedure for measuring overall severity of psychiatric disturbance. Archives of General Psychiatry, 33, pp.766–771.
NICE (2004) Self-Harm: The Short-Term Physical and Psychological Management and Secondary Prevention of Self-Harm in Primary and Secondary Care: Clinical Guideline 16. London: National Institute for Clinical Excellence.
McMillan, M. (2001) The reliability and validity of Freud’s methods of free association and interpretation. Psychological Inquiry, 3, pp. 167-175.
Sansone, R.A., Wiederman, M.W. & Sansone, L.A. (1998) The Self-Harm Inventory (SHI): development of a scale for identifying self-destructive behaviors and borderline personality disorder. Journal of Clinical Psychology, 54, pp.973-983.
Weissman, M.M. (1975) The assessment of social adjustment. Archives of General Psychiatry, 32, pp.357–365.
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