Chapter 16 Psychodynamic principles and boundaries

The quote above is from Winnicott (1949): on likening the care for the psychotic or difficult patient to a mother caring for a demanding baby.

Psychodynamics can be simply described as the understanding and study of the conscious and unconscious motivations that underlie human behaviour. They can be explored from the perspective of the individual’s psychological functioning and from the interaction between people and groups of people. This brief chapter provides a glimpse into the role that psychodynamic principles can have in risk assessment and management. A psychodynamic contribution to risk assessment adds information which cannot be obtained from standardised rating scales, but which can be of use in understanding the meaning and function of the risk behaviour for the patient. As well as exploring the psychological functioning of the patient, this contribution looks at the interaction between the therapist, the patient and others involved. It examines the therapist’s responses and it allows for a more meaningful interpretation and understanding of the risk behaviour. Ultimately this will lead to a more useful formulation of the risk and how it can be explained in the context of the patient’s illness, their interaction with their friends and family, and also their interaction with health professionals.

Taking a psychodynamic approach to the clinical presentation allows for an explanation of the mechanisms driving the risk behaviour. Risk behaviours (e.g. violence, suicidality, etc.) usually occur when an affect fails to be contained, regulated or linked to other mental mechanisms by thinking. Repetitive risk behaviours can be explored using the concept of repetition compulsion (see glossary). Past acts can be explored to discover their meaning for the patient and their continuing function in the here and now.

Considering the following questions will help develop understanding of the risk behaviour which simple exploration of the risk factors will miss.

Certain types of risk tend to promote more fear or rescuing behaviour on the part of some clinicians. To understand this involves an exploration of the transference and counter-transference (see glossary). What information does this give the clinician about the nature of the risk for the patient?

Asking questions about fantasy will give further information which may help make sense of the risk behaviour, especially violence and sexual risks. For patients with chronic risk, a central theme of the treatment is an exploration of the emotions and cognitions driving the behaviour. For patients with ‘time-based and contingent suicidal intent’³ (see page 137), the proposed date of death is a communication whose meaning needs to be explored before it can be managed.

Psychodynamic approaches can also be used to explore individual and group responses to perceived risk. Fear, anxiety, anger, panic, denial and so forth can be considered at both an individual and a group level. Individually, a clinician may reflect on their own practice but can also use supervision and second opinions. In a team which is functioning healthily, group discussions will be facilitated by the team leader and will help reduce the likelihood of a collective abuse of emotional responses. Other group responses to perceived risk, such as rejection, scapegoating, malignant alienation,⁴ victimisation, prejudice, stigma and so forth, can also be explored with good facilitation by the team leader.⁵

With experience, clinicians begin to recognise counter-transferential responses in certain types of clinical situations and, as the likelihood of acting on them reduces, these responses can be utilised as tools both in helping to make the diagnosis but also to assist in exploring the meaning of the risk.

The following exercises are very brief vignettes which are designed to demonstrate common clinical scenarios in which an emotional response on the part of the clinician is likely to occur. Many clinicians will have anecdotal stories where the emotions on the day affected good clinical management — focussing on psychodynamic principles should reduce this risk.

Related posts:

What is risk? Why focus on risk? The context of risk Personal (clinician) responses to risk Risk assessment: focus on documentation Managing adverse outcomes

Clinical Risk Management