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정신분석적사례이해
작성자  simonshin 작성일  2017.02.12 14:12 조회수 725 추천 0
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 사례이해와 심리치료의 관계  
첨부파일 : f1_20170212141402.pdf
 

과목: 정신분석적 사례이해

주제: 사례이해와 심리치료의 관계

강사: 신현근 박사

내용: 강의안

교재: McWilliams, N. (1999). The relation between case formulation and psychotherapy. In Psychoanalytic Case Formulation (pp. 9-28). New York: International Guilford Press.

 The Relation between Case Formulation and Psychotherapy 

 

1.      Overview

1.1.   THIS book represents an elaboration of my deeply held conviction that for therapy to be therapeutic, it is more important for the clinician to understand people than to master specific treatment techniques

1.2.   I look with dismay on the current enthusiasm for generating “empirically validated treatments” (“EVTs”) and teaching this collection of symptom-specific and manualized strategies as if it represents the essence of the psychotherapy process.

1.2.1.      The excitement over EVTs has created a growth industry in some sectors of the mental health economy—if you own the rights to a quick and empirically supported treatment for a problem that has attained a DSM label, you can probably retire tomorrow—but it threatens to do so at the cost of depriving beginning therapists of a vast and clinically invaluable literature on the treatment implications of any human being’s individual psychology.

1.2.2.      It seems to me self-evident that unless one understands someone’s unique, personal subjectivity, one cannot infer the best treatment approach for that individual.

1.2.3.      The current economic and political pressures to redefine psychotherapy as a set of short and symptom-targeted procedures are so patently incompatible with the intellectual and professional motivations of most practitioners as to be laughable.

1.3.   In what follows, I talk almost exclusively about the implications of a good case formulation for psychoanalytically oriented treatment.

1.3.1.      I hope readers of other orientations will nonetheless be able to make the necessary translations into their own favored concepts and find the material applicable to their work.

1.3.2.      I do not think psychoanalytic treatment is the only way to help people, and in fact, I think a good psychodynamic case formulation can be an excellent basis for designing a cognitive-behavioral treatment or family systems therapy or other intervention.

 

2.      Basic premises

2.1.   In creating a psychodynamic case formulation, the interviewer’s aim is usually to increase the probability that psychotherapy for a particular person will be helpful.

2.2.   Because the whole point of a dynamic formulation is the development of interventions that will achieve certain therapeutic goals, it may be helpful for me to say a few things about the goals of psychotherapy as they are understood by most psychoanalytic practitioners.

2.3.   When we talk about improvement in therapy, we refer implicitly to a range of goals that go beyond relief of the specific problem for which a person has sought help.

2.4.   Some clients share the treater’s broader vision of health and growth implicitly at the outset of treatment, and others come to it out of identification with the therapist during the course of their therapeutic work.

2.5.   This vision of the objectives of therapy includes the disappearance or mitigation of symptoms of psychopathology, the development of insight, an increase in one’s sense of agency, the securing or solidifying of a sense of identity, an increase in realistically based self-esteem, an improvement in the ability to recognize and handle feelings, the enhancement of ego strength and self-cohesion, an expansion of the capacity to love, to work, and to depend appropriately on others, and an increase in the one’s experience of pleasure and serenity.

2.6.   In addition, there is empirical as well as anecdotal evidence that when these changes occur, other specific improvements happen as well, including better physical health and greater resistance to stress.

 

3.      Goals of traditional psychoanalytic therapy

3.1.   Symptom relief

3.2.   Insight

3.3.   Agency

3.4.   Identity

3.5.   Self-Esteem

3.6.   Recognizing and handling feelings

3.7.   Ego-Strength and Self-Cohesion

3.8.   Love, work, and mature dependency

3.9.   Pleasure and security

 

4.      Case formulation for therapeutic rather than research purposes

4.1.   With the preceding objectives in mind, it becomes clear that what a therapist is doing when he or she makes a dynamic formulation is a very different process from the symptom-matching exercise that comprises diagnosis in accordance with the DSM.

4.2.   As I have argued elsewhere (McWilliams, 1998), therapists and researchers bring very different sensibilities to the diagnostic process

4.3.   Researchers in the empirical, positivistic tradition use parsimony as a criterion of explanation, while practitioners are repeatedly impressed with multiple and overlapping causation, or what Waelder (1960) called “overdetermination” (see Wilson, 1995).

4.3.1.      In other words, in a research project, one tries to isolate variables so that a particular cause-and-effect process can be exposed, uncontaminated by other possible explanations.

4.3.2.      In understanding the meaning of a problematic behavior, in contrast, one typically finds many contributants, none of which alone would have created the symptom.

4.3.2.1.            Anything important enough to have become a major problem to a person is usually overdetermined, not caused by a discrete variable.

4.4.   In analytic therapy, it is the unraveling of many different strands of causation that eventually permits patients to get mastery over patterns they seek to change.

4.4.1.      Therefore, when trying to come to an understanding of a complex human being and his or her complex difficulties, a therapist is silently pondering several related questions while drawing out and listening to the client.

4.5.   Usually, a therapist has a few interconnected ideas about the sources of a particular client’s suffering and finds that while investigating in those areas, all kinds of other realms open up.

4.5.1.      A dynamic formulation is only the roughest kind of mapping of someone’s individuality, but it is essential to have some kind of map before we invite a person into a terrain where both parties could otherwise get lost.

 

5.      5. Summary

5.1.   Psychodynamic case formulation attempts an understanding of a person that will inform the direction and tone of treatment.

5.2.   It is a more inferential, subjective, and artistic process than diagnosis by matching observable behaviors to lists of symptoms.

5.3.   It assumes a concept of psychotherapy as involving not only symptom relief but also the development of insight, agency, identity, self-esteem, affect management, ego strength and self-cohesion, a capacity to love, work and play, and an overall sense of well-being.

5.4.   I have argued that an interviewer can generate a good tentative formulation of a person’s personality and psychopathology if he or she attends to the following areas:

5.4.1.      temperament and fixed attributes,

5.4.2.      maturational themes,

5.4.3.      defensive patterns,

5.4.4.      central affects,

5.4.5.      identifications,

5.4.6.      relational schemas,

5.4.7.      self-esteem regulation, and

5.4.8.      pathogenic beliefs.

 
 
 
 
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