“How would you handle a person severely depressed with suicidal ideation (within a psychiatric unit)? After a fully functional life she suddenly remembered an early incident of sexual molestation. Her anxiety is very high. She is withdrawn and numb.” Thanks to one of our anonymous readers who sent this question.
Of course, without seeing the patient we can only speculate. So, instead, let’s get clear about the assessment questions we need to keep in mind when working with this patient. Let’s start with the triangle of conflict. We can safely hypothesize that recovering the memory of sexual molestation has triggered a very large rise of complex feelings. These feelings have triggered her anxiety. And her defenses, from what we have heard, include turning rage on the self (suicidal ideation), withdrawing from her feelings, and numbing herself.
Given that the patient is in a psychiatric unit we want to assess her anxiety. Which channels of unconscious anxiety discharge does her anxiety go into? High anxiety could go into purely striated muscles, or it could go into the smooth muscles and cognitive/perceptual disruption. If her anxiety is going into the striated muscles, the therapist can explore feelings freely and hope for a rather quick treatment. However, if the patient’s anxiety goes into cognitive/perceptual disruption, the patient’s pathway of anxiety discharge will have to be restructured. And most likely she suffers from high superego pathology (e.g., character defenses, transference resistance, or projection of the superego). And this superego pathology would have to be addressed quite thoroughly in order for the pathway to feeling to become available.
As the therapist explores the patient’s feelings about the molestation memory, she would assess not only the patient’s anxiety but also what kinds of defenses the patient uses. Does the patient also use repressive defenses such as intellectualization (good sign) or are all of her defenses regressive? (bad sign) This assessment would allow the therapist to see how much affect the patient can tolerate, what risk she has for acting out, her reality testing, and what degree of defense restructuring the patient needs.
As the therapist explores the patient’s feelings, she will see whether the patient becomes more firm and steady with a rise of feeling (good sign) or whether she starts to flatten out (depression), become confused and disorganized (cognitive/perceptual disruption), or suffer physical symptoms (somatization). This will allow the therapist to see what level of feeling the patient can tolerate without regressing, the highest level where the therapist should try to work at with the patient.
As the therapist explores feelings, she should assess whether the patient can observe and pay attention to her feelings, anxiety, and defenses. If she can’t pay attention to her feelings, she won’t be able to access them as deeply as possible. If she can’t pay attention to her anxiety, she won’t be able to regulate it. If she can’t observe her defenses, she will keep using them and suffer the symptoms that result from those defenses. Whatever observing capacities the patient lacks, the therapy must rebuild.
As the therapist explores feelings, she should assess whether the patient can see the triangle of conflict that generates her symptoms. Can the patient differentiate her feelings from her anxiety and defenses? Can the patient let go of the defenses that hurt her? If not, mobilize those missing capacities.
And as the patient is able to tolerate a higher rise in feeling, does she continue to use defenses against feeling, or does she shift into avoiding contact with the therapist. If so, then the therapist must focus on those defenses against contact, what we call the transference resistance.
We can’t know what to do with any patient until we know what is going on. To know what is going on, we explore feelings. The patient’s responses of anxiety, defense, and self-observing capacity show us her strengths and weaknesses. They show us what we need to treat. Gently explore feelings so you can assess the patient’s responses and conduct a thorough psychodiagnosis. Her responses of feeling, anxiety, and defense will tell you what strengths she has and what weaknesses you need to strengthen so you can access her feelings as deeply as possible. In my book, Co-Creating Change, there is an entire chapter on just the topic of psychodiagnosis.