Psychotherapy Written Case

Read the detailed psychotherapy written case of a patient named Tracey, including assessment, management plan, clinical progress, and more. Get insights into the patient's demographics, history, and psychiatric background.

The Royal Australian and New Zealand College of Psychiatrists
Psychotherapy written case
Date of submission:
Patient’s pseudonym: “Tracey”
Word count:
(Excluding cover sheet, contents page and references)
De-identification disclaimer;
In accordance with psychotherapy Written Case Policy and Procedure 11.1, all data
which could potentially identify the patient, their family and other individuals have
been removed from this case report. Pseudonyms are used for all names in this case
report and are marked with an asterisk (*) the first time they appear in the text. All
data that could potentially identify the patient, such as locations and dates, have been
removed from this case to maintain confidentiality.
1

Table of Contents
ASSESSMENT..............................................................................................................4
Demographics............................................................................................................4
Referral.......................................................................................................................4
History of presenting illness......................................................................................4
Past psychiatric history..............................................................................................6
Medical history..........................................................................................................6
Medications................................................................................................................7
Substance use history.................................................................................................7
Forensic history..........................................................................................................7
Family history............................................................................................................7
Personality................................................................................................................11
Mental state examination (MSE).................................................................................11
Risk assessment............................................................................................................13
Physical examination and investigations.....................................................................13
Communication/Liaison...............................................................................................13
Provisional diagnosis –As per the Diagnostic and Statistical Manual of Mental
Disorders (DSM)-5 classification4...............................................................................16
Differential diagnosis (DD).....................................................................................17
1.Adjustment disorder with depressed mood...........................................................17
MANAGEMENT PLAN.............................................................................................18
Biological treatment.................................................................................................18
2

Sociocultural approach.............................................................................................18
Psychological treatment –choice of therapeutic model............................................19
Supervision...............................................................................................................21
Therapeutic frame, contract and setting...................................................................21
CLINICAL PROGRESS..............................................................................................23
Assessment (1-3)......................................................................................................23
Early Phase -sessions (4-15)....................................................................................24
Middle Phase-sessions (16 -26)...............................................................................30
Late Phase - Sessions 27-37.....................................................................................33
Termination (38-42)................................................................................................35
Reformulation..........................................................................................................36
Supervision...................................................................................................................38
Communication and liaison.........................................................................................39
My learning as a trainee...........................................................................................41
3

ASSESSMENT
Demographics
Tracey* was a 66-year-old married Asian woman who resided in an urban
setting with her husband Chris*, aged 67 years. Tracey was a homemaker, and her
husband was plasterer. Together, the couple had three children-twin Sons John* and
Jimmy* and daughter Sandra*. John, aged 45 years and Sandra, aged 36 years were
both married and lived locally. Jimmy, one of the twins died from an unintended
overdose, at the age of 22 years.
Referral
Tracey was referred for psychotherapy by Raj*, her Dialectical Behaviour Therapist
(DBT) who noted that Tracey wanted to talk about her past traumatic experiences
during the DBT sessions which she had attended for approximately one year. Raj was
of the opinion that Tracey would benefit from long-term psychodynamic
psychotherapy. He referred her to the local psychotherapy programme, the
coordinator of which referred her to me knowing that I was looking for a person for
whom psychodynamic psychotherapy would be suitable and more likely to be helpful.
I discussed Tracey with my psychotherapy supervisor, and after initial assessment,
she was considered appropriate for long term dynamic psychotherapy.
History of presenting illness
Tracey referred herself to the local community mental health team (CMHT) one year
ago, after her son John moved out of the family home, which left her feeling alone
and abandoned with deteriorating low mood, irritability and poor energy. She also
reported poor sleep, low self-esteem, chronic suicidal ideation, feelings of emptiness,
and erratic appetite. She reported that these symptoms were present since her teenage
4

years and worsened in the context of her son leaving home. She reported periods of
“comfort/binge eating” when she was stressed but there was no reported weight loss
or gain. She stayed awake to watch documentaries till late and said it was because she
could not get to sleep. She said, "I have been depressed throughout my life, never
came out of it". She described poor self-care, social isolation and expressed
difficulties in caring for her grand-daughters, "I love them and enjoy them but find it
hard to manage… feel tired and exhausted."
In addition, her marital relationship posed an on-going stressor. Chris was extremely
critical of her and prevented her from maintaining a close relationship with her
daughter and granddaughters. Tracey was unable to pursue her hobbies, namely
painting and playing the piano, due to feeling tired but reported enjoying time with
her granddaughters and attending an Alcoholic Anonymous (AA) group twice a
week. She denied having any close friends, and her social circle was restricted solely
to her AA group. Her concentration, she said was good as evidenced by her spending
hours watching TV, documentaries and reading books. Tracey’s presenting illness
could be said to be a continuation of a persistent dysthymic state.
There were no features suggestive of psychosis, mania, anxiety disorders
including obsessive-compulsive disorder (OCD) and Post Traumatic Stress Disorder
(PTSD). She was diagnosed with persistent depressive disorder and borderline
personality disorder by CMHT. CMHT offered DBT as Tracey was reluctant to take
medication but was interested in individual counselling. In spite of DBT for one year,
her aforementioned symptoms persisted, though she reported reduced suicidal
ideation. She was referred for long term psychotherapy as stated above. The CMHT
agreed to remain involved in Tracey’s clinical care while she undertook individual
psychotherapy with me.
5

Past psychiatric history
Tracey had experienced depressive symptoms and chronic suicidal ideation since her
teenage years; however, she denied self-harm or suicidal attempts. Tracy’s first
contact with mental health services was at the age of 35 years when she had a brief
psychotic episode, for which she was admitted to hospital. Tracey elaborated the
circumstances leading to this admission. Prescription of phentermine (Duromine) by
her general practitioner for weight loss, she said, triggered her paranoid symptoms .
She said that her four-year-old daughter Sandra’s vaginal infection made her
suspicious that her husband had sexually abused her. She believed that all fathers
were portrayed on television, and the spouses of her friends were sexually abusing
their daughters. She responded well to cessation of phentermine and brief
antipsychotic medication.
Tracey mentioned that her depressive symptoms continued due to ongoing
relationship difficulties with Chris and other life stressors. Since then, Tracey had
approached the CMHT few times in crisis, including at the time of her son's death by
an accidental heroin overdose when she was 45 and again few years later when her
daughter moved to England for further studies. She chose not to be on medication and
received some supportive counselling. Due to ongoing relationship difficulties with
Chris, she sought marriage counselling and domestic violence counselling with
limited benefit. No further instances of psychotic episodes, hospital admissions, or
emergency presentations were reported.
Medical history
There was no known history of hypertension, diabetes, thyroid abnormalities, head
injury, epilepsy or any surgeries.
6

Medications
She was not on any medication.
Substance use history
Tracey reported consuming alcohol since she was 14 and gradually began to binge
drink when she was expelled from her church at the age of 19. This drinking pattern
escalated following her marriage. In her words, she was “psychologically addicted to
alcohol but drank too much when I drank”. Following her sole psychiatric admission
at the age of 35, Tracey ceased all alcohol consumption, and she had remained sober
since. This was supported by regular attendance at AA. She was non smoker and
denied use of prescribed or illicit recreational drugs.
Forensic history
Tracey denied any forensic history.
Family history
Several family members suffered from depression. Tracey reported that her parents
were diagnosed with anxiety and depression. Her half-sister Lisa* was diagnosed with
depression and committed suicide by hanging at the age of 33 while she was receiving
medications for depression. Furthermore, Tracey’s younger brother and his daughter
were diagnosed with depression. Sandra experienced postpartum depression following
her two pregnancies. Besides this, Sandra and John both were diagnosed with anxiety
and were receiving counseling for the same.
Personal, Developmental, sociocultural History
Family of origin and early life
Tracey reported that both her maternal and paternal grandparents had problem
drinking. She described them as suffering from the experiences of war and the trauma
7

of forced migration. Both of Tracey’s parents’ families were born in central Asia and
moved to East Asia when her father was 12, and her mother was seven years old. As a
result, they lost contact with their extended families. According to Tracey both her
parents had a history of neglect and physical abuse as children. Tracey’s mother
never worked, and her father was an electrician, and both were heavy drinkers.
Tracey's family belonged to a conservative Christian denomination. Her father was a
committed Christian, and church activities played a significant role in their lives.
Tracey was born in East Asia. Tracey accomplished fine motor, gross motor, social
and language milestones within normal limits. Tracey was the third of eight siblings,
which included three biological brothers, three biological sisters and one elder half-
sister Lisa from her mother’s previous relationship. Her parents migrated to Australia
with Tracey and her siblings when she was six years old. Tracey’s six-year-old
younger brother died of Diphtheria the year after they moved to Australia and she
reported extreme guilt for his death saying, “ guilt is my default state, want to escape
from the feeling of powerlessness."
Tracey described a traumatic and chaotic family life with memories of considerable
physical abuse by her father, an emotionally absent mother who did not “protect”
them from their father. Tracey revealed that her father sexually abused Lisa, her half-
sister from the age of 5-15 years and possibly herself but did not elaborate it further.
Tracey mentioned, "My mother did not know how to use soothing words”, "As a
child, I grew up to hate myself." She said that “Mother or father never left the house,
but a child knows that they are not there." In her own words "our family was not the
best family ….due to the incest reported by mum". She learnt to put on a happy face
and to please others to survive.
8

School
Tracey reported that her primary school years were uneventful. However, the
transition to high school was a difficult period as Tracey’s mother was expelled from
the church at this time. This was due to complaints made by Tracey’s father
concerning her mother having an abortion against his wishes. This, in turn, created a
significant negative impact on Tracey’s friendships, as most of her peers at the church
isolated her. In addition to this, Tracey was marginalised and bullied at school,
causing her to leave school in the middle of year nine. According to Tracey that was
the beginning of her depression from which she never fully recovered. After leaving
high school, Tracey was busy looking after her younger siblings.Tracey also felt
abandoned and humiliated as a result of being barred from the church, when she was
19 years, on the grounds of not living up to the standards of the church. Since their
excommunication, Tracey and her mother have remained atheists.
Marriage, children and further losses
Tracey denied any premarital relationship. She married Chris at the age of 20 and left
her parents’ home. She endured verbal, emotional and physical abuse in her marriage.
Her husband often attempted to choke her. Tracey made statements such as “I don’t
know what love is, I like him and find him attractive, "He is my gift - the trigger for
trauma" suggested the distress associated with her marital life, her ambivalence
towards him, and her helplessness in the relationship. Tracey reported using sex to
pacify her husband.
She gave birth to twin boys John and Jimmy at the age of 21 and daughter Sandra was
born when Tracey was 30. Tracey reported having a distant relationship with her
children. She attributed it to "misuse of alcohol, the family history of incest and her
9

own emotional unavailability." She admitted, "I never hugged and kissed my
children."
When Tracey was 25, her half-sister Lisa committed suicide by hanging. Tracey was
very close to her and blamed herself. When Tracey was 43, her son Jimmy died of an
accidental overdose of heroin at the age of 22. According to her, it was the biggest
loss in her life.
Her other son John operated a construction business and his three adult children (24,
22, 16 years) seemed to have settled lives. Her daughter Sandra worked as a part-time
receptionist* and Tracey provided childcare to her daughters (5 and 3 years) while she
worked.
Tracey’s relationship with her parents remained strained. Tracey's mother continued
to drink excessively and was admitted to a nursing home where she died at the age of
80. (Tracey was 52) . Three years later her father died of a lung infection at the age of
85. She felt remorseful for not being able to look after her parents, as evident from her
repeated statement "….I wasn't of much help to them”.
Her younger brother (now 64) was raped when he was five -years- old and became
depressed in his teenage years. She denied having any fights or confrontations with
her siblings and said she loved them dearly. The rest of her siblings were alive, but
she had limited contact with them.
Tracey denied any physical abuse from her husband Chris in the last five years but
reported ongoing verbal and emotional abuse to which she usually responded with
sarcasm and verbal hostility.
Employment
10

Tracey started to work in a restaurant as a kitchen hand at the age of 18 and
continued until her children were born. She then completed an accountancy course,
although she did not work for the next 4-5 years. When Tracey’s children reached
primary school age, she worked on and off as a cleaner and data clerk. At the age of
43 when Jimmy died, she ceased all employment and distracted herself by pursuing
online psychology and natural hygiene courses. At the age of 48, she returned to work
part-time as a yoga instructor for the next 14-15 years. She left this employment at the
age of 62 to provide care to her granddaughters and had not worked since.
Personality
Tracey described herself as a “people pleaser” and an accommodating person, stating
that she longed for affection and love. She had a constant fear of being abandoned,
and worried about people judging her. This made it difficult to form friendships, and
she denied having any friends. She referred to herself as a "homing pigeon".
Mental state examination (MSE)
Appearance and behaviour
Tracey was an Asian woman of stated age, well-kempt, and casually dressed in a
grey and white striped t-shirt, pink joggers, and white pants. She wore glasses and
was tall and moderately overweight. She was well-mannered, polite and engaged. Her
open posture was evidence of her interest in our discussion. She maintained good eye
contact. She presented as very compliant and accommodating.
Mood and affect
11

She reported her mood to be low. Her affect was reactive and congruent with her
mood. She became teary while discussing her parents and the demise of her siblings
and son.
Speech
Her speech was fluent and well-articulated with a good vocabulary. She had normal
prosody and volume in her speech.
Thought form and content
There was no evidence of formal thought disorder. Thought content included themes
of low self-esteem, emptiness, worthlessness, shame, and guilt. She ruminated about
her traumatic childhood experiences and marital issues. She denied any persecutory,
paranoid or nihilistic delusions. There was no evidence of obsessional thinking. She
reported chronic fleeting suicidal thoughts but denied any current self-harm, suicidal
or homicidal thoughts.
Perception
There was no reported auditory, visual or other perceptual abnormalities and she was
not observed to be responding to internal stimuli.
Cognition and orientation
She was oriented in place, time, and person and scored 30/30 in the Mini-Mental State
Examination (MMSE).
Insight and Judgement
Tracey demonstrated good judgement and insight into her current situation. She was
motivated to undertake therapy to understand her life's complexities and wanted to
improve her relationships with her husband and children. She expressed a strong
desire to " understand myself more and find answers to my difficulties, why I am not
12

getting better."
Risk assessment
Immediate risk
At initial assessment,Tracey denied any thoughts of self-harm or suicide and
identified her family and grandchildren as protective factors. Absence of current
substance use, her good insight, and motivation further lowered any risk of self-harm
or harm to others.
Long term risk factors
There were several significant historical risk factors that needed to be taken into
account: the presence of a major mental illness, early childhood adversities, chronic
suicidal thoughts, previous substance use, and family history of mental illness and
suicide. However at the time of presentation she was at a better time in her life with
less dynamic risk enabling her to be reflective.
Physical examination and investigations
Examination of the cardiovascular, neurological and other systems performed by
Tacey’s GP was unremarkable and results of recent investigations such as CT brain,
renal function tests, complete blood count, liver function tests, thyroid function tests,
blood glucose level, folate level, vitamin B12, and iron levels were within the normal
values.
Communication/Liaison
With Tracey's consent, I communicated with her GP and obtained relevant clinical
information - medical history, current physical state and blood tests. Furthermore, I
obtained a comprehensive handover from her DBT therapist, and the case manager
13

and the psychiatrist from the CMHT. Considering her excellent relationship with DBT
therapist and CMHT, liaison made her feel valued.
Initial Psychodynamic formulation
Tracey was a 66-year-old married woman who was referred for long term
psychotherapy in the context of worsening depressive symptoms and ongoing
interpersonal conflict that had responded partially to DBT. The recent departure of
her son from the family home likely reactivated feelings of abandonment and losses
that she had previously experienced and also served to exacerbate chronic feelings of
low self-worth and guilt. The continuing marital conflict with her husband, social
isolation and multiple losses in her life were maintaining factors for her chronic low
mood.
Her initial presentation may be further explained by the interaction of biological,
developmental and social factors. Tracey was genetically predisposed to depression
and personality vulnerabilities based on a history of depression in multiple family
members.
From a developmental perspective Tracey had experienced considerable trauma in her
early life. A lack of emotional sensitivity and chronic devaluing and invalidation from
primary caregivers who also frequently abused alcohol likely led to the development
of an insecure, anxious-ambivalent attachment. Epidemiological research has shown
that parental alcohol use disorder predisposes to social isolation,chronic low self-
esteem , anxiety disorders and higher lifetime rates of dysthymia in their children.1
Verbal, physical, and possibly sexual abuse by primary care givers may have fostered
feelings of low self-esteem and worthlessness and led to her personality
vulnerabilities. It has been found that chronic childhood adversities including family
14

dysfunction and abuse are known to be the most consistent predictors of various
psychopathologies including mood disorder, anxiety and substance use at almost all
stages of a person's life.2
Social factors including the trauma of relocation3, death of a younger sibling, loss of
education, excommunication from her church and social peer group, and death of her
half-sister and son may have deepened her sense of rejection, alienation, and further
reinforced her poor self-esteem.
Tracey seemed to have adapted by unconsciously developing a style of interpersonal
relating characterised by over compliance and an eagerness to please to prevent future
abandonment. Furthermore, I speculated that her chronic need to please was as a
result of her negative perceptions of herself and her poor self-esteem. Tracey’s heavy
alcohol use can be viewed as another coping mechanism, used to distract from her
intense emotional pain.
The unexpected death of her half-sister by suicide and Tracey’songoing life stressors
contributed to the development of her brief psychotic episode but was also an
important turning point. It was the beginning of self-activation and fuelled a move
towards self-improvement, including committing to abstinence from alcohol.
Additionally, Tracey appeared to have some inner resilience which was helped by her
therapeutic contacts and she sought to improve by doing online courses.These helped
to bolster her self-confidence and distracted her from ruminating on the adverse
events in her life.
There were several positive prognostic factors including : Tracey's normal
intelligence, good physical health, her psychological mindedness, her capacity to form
and maintain therapeutic relationships with her care providers, and motivation to
15

explore her traumatic experiences. I saw our therapeutic relationship as being
grounded in empathy, understanding,unconditional positive regard and acceptance
which would provide her a secure base from which she could obtain nurturance while
strengthening her sense of self and improving her interpersonal relationships. I felt
optimistic for Tracey’s progress.
Provisional diagnosis –As per the Diagnostic and Statistical Manual of Mental
Disorders (DSM)-5 classification4
1. Persistent Depressive Disorder PDD (Dysthymia) Specifier: Partial remission
with pure dysthymic syndrome, early onset
Tracey met the criteria for Persistent Depressive Disorder (PDD) including chronic
low mood, fluctuating appetite, fatigue, poor self-esteem and long-standing sleep
disturbances since her teens, from which time she had never been symptom-free for
more than two months at any time. She reported depressed mood for most of the day,
for more days than not.
There was no history suggestive of any current hypomanic or manic episodes,
schizophrenia, schizoaffective disorder or enduring psychotic disorder.Her brief
episode of psychosis was possibly associated with phentermine,an amphetamine
derivative,known to induce psychosis.5
2. Borderline personality disorder
The diagnostic criteria for borderline personality disorder were fulfilled. Tracey
displayed chronic sensitivity towards perceived or real abandonment.She had an
enduring pattern of unstable relationships with her parents, children and husband. She
both idealised and devalued her husband and on one occasion stated, “he is my gift….
he is my trigger for trauma”. Tracey reported a poor sense of self, chronic feelings of
16

emptiness, chronic suicidal thoughts and impulsiveness in the form of alcoholism in
the past and binge-eating currently. She reported difficulties in controlling her anger
which manifested as verbal outbursts, sarcasm and enduring bitterness towards her
husband.
Differential diagnosis (DD)
1.Adjustment disorder with depressed mood
Tracey described a worsening in her mood since her son moved out of their home.
However, the chronicity of her low mood, with no intervening improvement in
symptoms was more in keeping with PDD.
2. Major depressive disorder(MDD)
Tracey’s description of low mood, fatigue, sleep disturbances, fluctuating appetite,
feeling of worthlessness might indicated possible MDD, but they were not present
most days nearly every day to fulfill the criteria for MDD. There was no convincing
evidence of psychomotor retardation or agitation, significant weight loss or gain and
poor concentration. These symptoms were present since her teenage years and she
denied any recent change in functioning. Therefore the diagnosis of PDD was more
suitable.
3. Mood disorder due to another medical condition
Tracey’s history, reports of physical examination by the GP and results of blood tests,
showed no direct correlation between her mood symptoms and the pathophysiological
outcomes of a particular clinical condition like hypothyroidism, anemia,stroke or
emerging dementia.
17

4. Substance/medication-induced depressive disorder
Tracey was not on regular medications. She had refrained from alcohol over the past
thirty years, and there was no history of illicit drug use.
Reflection on the assessment :
Tracey was spontaneous and forthcoming, and I was able to perform a comprehensive
assessment. The absence of collateral history from her husband or other family
members was a notable deficiency in the assessment. Though the notes from CMHT
included collateral from the family.
MANAGEMENT PLAN
Biological treatment
Tracey was resistant to the idea of pharmacotherapy. She clearly stated ‘I don’t take
any medications and it is a very important thing for me not to." She explained that this
reluctance was due to the sudden death of her son following an overdose of heroin,
her half-sister committing suicide while on multiple antipsychotic medications, and
her previous psychotic episode that was likely triggered or exaggerated by Duromine
administration. I appreciated her wish and acknowledged her willingness to work in
therapy.
Sociocultural approach
Tracey expressed the wish to improve her relationship with her husband and children.
We agreed to work towards addressing interpersonal difficulties and aimed for more
active participation in hobbies. Taking into consideration the fact that Tracey was an
atheist, I made considerable effort to respect her values and principles.
18

Psychological treatment –choice of therapeutic model
A plethora of factors determined Tracey’s appropriateness for psychodynamic
psychotherapy. She was psychologically minded and demonstrated a deep interest in
understanding herself, and the reasons behind her suffering. She was willing to
collaborate, no longer used drugs or alcohol, and had previously engaged well with
past therapists. These factors made her a good candidate for psychotherapy.6
A range of psychological therapies was considered during supervision.
Interpersonal psychotherapy (IPT) is effective in the treatment of depressive illness
and also improves chronic interpersonal relationship problems.7 Cognitive Behavior
Therapy was also considered due to its potential benefit in helping Tracey to
challenge her maladaptive thoughts that were underlying her poor self-esteem, low
self-worth, and excessive guilt. However, these time-limited and structured therapies
were less likely to assist with Tracey’s history of trauma, longstanding difficulties,
poor sense of self and poor interpersonal relationships. In contrast, Tracey’s persistent
depression on the background of a traumatic childhood and marked interpersonal
difficulties made psychodynamic psychotherapy a good treatment option.
Psychodynamic psychotherapy is an evidence-based treatment for depression and
borderline personality disorder8,9. It has been found beneficial in improving
interpersonal functioning, suicidal behaviour and associated psychopathology in
personality disorders. It results in long-lasting gains in mood and functioning even
after cessation of therapy.10-13
The psychodynamic model considered in this case was the Conversational Model
(CM) of psychotherapy. The Conversational Model, named by Robert Hobson (1920-
1999) is among the best validated of currently employed psychotherapies.14. The
19

theoretical framework of the Conversational Model encompasses firstly the
development of self in the therapeutic relationship which helps to process
unconscious traumatic memories and furthermore help integrate them into the self-
system.14
The aim was to provide Tracey with a relationship that would acknowledge, recognise
and understand her as a person, providing her with a secure base to explore her
traumatic experiences which hitherto, had hindered her healthy self-development, and
allow her to develop a sense of self.
The limitations of Psychodynamic psychotherapy
Due to the need for frequent sessions and prolonged time required, Psychodynamic
psychotherapy can risk dependency in a patient.The other limitation is when a patient
sees the therapist as invariably wise and infallible which leads to decrease capacity of
independent judgment and risks “intellectual incest”15.Timely and planned termination
and involving patient in decision making instead of giving advise can help to
overcome this limitations.
Goals of therapy
Tracey identified the need to have a better understanding and awareness of how
her traumatic experiences continued to impact her life. She stated, “I need insight into
myself; I have been depressed my whole life”. Other goals of therapy included;
improved self-esteem, reduction in depressive symptoms, and better relationships
with her children and husband. As a psychotherapy trainee, my aim was not only to
20

gain experience in providing psychodynamic psychotherapy but also to provide a
secure base for Tracey to improve her reflective capacity and strengthen her sense of
self.
Supervision
The primary purpose of receiving supervision, in this case, was to guarantee my
efficacy in psychotherapy practice while providing therapy to Tracey. I was already
receiving individual psychotherapy supervision in person weekly for 30 minutes
during the previous two months, from a senior psychiatrist psychotherapist who
helped me to understand psychodynamic psychotherapy and the Conversational
model that I intended to use, in addition to gaining theoretical information that
prepared me to embark on therapy with my patient. I continued to receive weekly
face-to-face supervision for 30 minutes from the same supervisor. I was also directed
to relevant references and encouraged to read as many papers I could.
Therapeutic frame, contract and setting
I openly discussed with Tracey that I am a psychiatric trainee therapist and that the
work with her would form a part of my training requirement besides I displayed a
genuine willingness to help her. We mutually agreed and contracted to meet for
weekly sessions at a particular time at the therapist’s office. Each session would last
for 50 minutes over a minimum duration of 40 sessions after which we could together
review the progress made. I emphasised the importance of weekly sessions and
explained that any planned or necessary breaks would be discussed in advance. I also
expressed to Tracey that her participation was entirely voluntary and at any point, if
she felt dissatisfied, we could talk about it and she could withdraw from therapy if she
21

wished. However, a four weeks' notice period was agreed upon, if she desired to
terminate therapy, in order to facilitate the discharge planning and therapeutic closure.
Tracey also provided voluntary, informed consent for the audio recording of sessions
and their use during supervision. Issues of confidentiality and anonymity, i.e. de-
identification were discussed, so also were the safety of the audio-recordings, therapy
and clinical notes.
I provided Tracey with necessary contact details if there was a need to
reschedule an appointment. I elucidated my accountability as a therapist and the
potential advantages of the (CMHT) for the current clinical care and liaison. I also
explained the need to develop clear boundaries during the psychotherapy process in
order to maintain a professional relationship. I reminded Tracey that I would be under
the continuous supervision of a senior psychiatrist psychotherapist specialised in this
modality of treatment. She knew that there would be no fee for therapy. Using the
principle of the Recovery Model16, Tracey felt empowered by making the final
decision of participating in the therapy after processing all the information provided to
her.
Potential difficulties and risks of therapy
Being a novice therapist, I was aware of my limited expertise in psychotherapy and
was concerned that Tracey would detect any uncertainties on my part. I also
considered her fear of abandonment, and the potential effect that breaks and ending
therapy could have on her. My supervisor suggested that it would be beneficial to talk
about the fact that this therapy is time-limited and that she would be helped to
transition to further therapy if there is a need. I also anticipated that the many
expectations of the therapeutic frame might overwhelm Tracey, particularly given her
22

accommodative and eager-to-please nature. Considering her past history, it was
anticipated that discussing previous trauma could trigger affective instability, so a
crisis management plan was drafted involving Tracey and the CMHT.
CLINICAL PROGRESS
Assessment (1-3)
The previous therapist introduced me to Tracey by inviting me to the last DBT
session. I was aware that the initial assessment is the most important in attempting to
form a safe therapeutic relationship, and that it is therapeutic in itself17. I listened to
her story, reflecting, acknowledging, and conveying my understanding of her in the
process, and trying not to interrupt her. I tried to follow the principles of the CM, i.e.
using statements rather than questions unless unavoidable. This allowed the process to
unfold as I began to learn more about Tracey and felt encouraged by her regular
attendance and her spontaneity.
After three sessions I shared my initial formulation with Tracey, to which she
responded: "you came to know me so early, you have got good understanding ”. This
was an example of her idealising me, and at the same time, I felt she was placing a
great responsibility on me as a therapist. I felt uneasy by the pressure to "not make a
mistake and keep her faith in me". My supervisor’s response to my need to be perfect,
was “it is sufficient to be a good enough therapist” by providing a secure and trusting
base.18 I felt assured that we had a good therapeutic relationship, which is considered
vital for successful psychotherapy.19
These sessions confirmed issues of Tracey's depression, her poor self -
23

esteem, and her idealisation which was a repetition of her habitual way of interacting
with others, pleasing them to avoid rejection or abandonment. I did not address the
transference, as it seemed too early and she may have felt judged by me. My
countertransference was one of feeling helpful and looked up to, for help. Her felt
insecurity was palpable, and so was her need to please me, which led me to believe
along with her history that she had an insecure attachment style.
Early Phase -sessions (4-15)
In these sessions, Tracey spoke more in-depth about her current and past experiences
with her parents and her husband. She did not talk about her son who died. My
supervisor suggested that early interrogation about traumatic experiences by the
therapist when the patient is not ready could disrupt the therapeutic relationship. I
waited until she was ready.
Though the CM is a phase-model, the therapy does not emerge in a
straightforward linear manner, but rather as a series of forward and backward
movement as a better sense of self is experienced in the last phase.
Empathetic attunement; Listening, understanding and reflecting
Tracey came regularly and was always 10-15 minutes early. I noticed brief
dissociation when her story was disconnected, i.e. it lacked continuity and was
fragmented.
Tracey: He is gaslighting me …there's no connection
Therapist: He? As per the CM, I used non-verbal and short verbal utterances to
show her that I was listening
Tracey: ….. have to make him happy all the time….
24

Therapist: have to make him happy all the time? I said this tentatively intending to
encourage her to tell me more about her experience of her husband
It seemed like that Tracey hadn’t heard my question, and was immersed in her
memories.
Anxiety in the therapist
As a novice therapist, I was not sure about the complexities of conversational
experience and felt anxious how best to respond in these situations. I felt nervous
before each of the next few sessions, wondering how they would start, and what I
should do and say.
My supervisor recognised my anxiety and emphasised that my role was to listen
and attune to Tracey, try to understand her and communicate that understanding to her
in an empathic manner. I tried to create a safe and secure therapeutic space for
Tracey by being on time, validating and valuing her disclosures. Tracey openly
expressed that she felt safe with me and started to share her personal experiences and
feelings. She often started sessions with self-blaming and self-criticism. A disjointed
narrative of her traumatic life emerged, and there was no space for me to intervene.
Her disclosure of traumatic experiences emerged much sooner than I expected and
had to be dealt with.
I began to understand from supervision that the emergence of traumatic
memories of Tracey's childhood, had the effect of destabilising her mental state as a
result of dissociation. Dissociation may also have been her way of coping with intense
distress in her earlier years.20 However, this gradually decreased as sessions
progressed.
25

Tracey’s account of her sufferings during her childhood and adolescence
gradually started to unsettle me as a trainee psychotherapist, and I had the urge to
conduct a brief risk assessment. My supervisor helped contain my anxiety, and in turn
I was able to return my focus from risk assessment to my therapist role, which was to
continue to provide her with a secure base for exploration.
Traumatic Memories
Tracey: "As a child, I grew up to hate myself" … "It was chaos at home; my sister
was running away, I couldn't trust my father."
Therapist:………..hmmm
Tracey: “My mother drank alcohol and didn’t protect me from my father”. "I didn't
respect myself; my safety was with an abuser, my father",
Therapist: …..hmm
Tracey: “I was addicted to my husband, I used sex to pacify him, there was no
empathy, no intimacy, no connection in marriage”, …. "I am trapped, and I am
trying to find a way to live my life, it is always exhausting around my husband."
Stimulus entrapment
I was confused and stayed with confusion. She was overwhelmed and outer oriented; I
felt that she often forgot that I was there. It was hard to interrupt or ask any questions.
I learned in supervision that she was “stimulus entrapped” and all I heard were
repeated accounts of happenings and people, with little affect.20 I felt excluded but
tried to stay with Tracey. My supervisor suggested that any attempt on my part to
26

request Tracey to slow down or repeat something I had not properly heard, would
result in her feeling alienated and misunderstood. My supervisor also acknowledged
my fear of uncertainty and suggested that I should not try to shape the session in what
I felt would be the right direction, but to simply stay with her, and allow her story to
unfold and that my responsive presence would help her feel understood.20
A sense of relatedness is established when a therapist gives importance to what
the patient says even if the content is incoherent, disconnected or hard to understand.
From this sense of relatedness coherence and connection will eventually emerge. The
patient feels understood and has trust in the sincerity of help offered when the
therapist leaves his/her own agenda aside and responds to what is given.20
Emerging coherence
I noticed that Tracey gradually became more coherent. As her sense of cohesiveness
began to develop our conversation took to another level. There was more affect, and
affect-laden words were used when she reflected on her childhood experiences, which
were exceedingly traumatic, and “nerve-racking”, involving shame, neglect and
abuse. While she narrated all her disturbing childhood experiences, I focussed on her
tone of voice, body language and affect and reflected my observations and
understanding of what she had been through.
Repetitive themes such as “I should never had children” or “I never held and
cuddled kids” evidently portrayed the shame she felt and her need for repentance that
she was not able to care for her children in a fitting manner.
Therapy frame:
27

Another important issue, which emerged, was that as a neophyte therapist I found it
hard to interrupt Tracey when the session was at its end, particularly if she was in the
midst of recalling traumatic experiences, which made the sessions last longer than
usual and continued for 70-80 minutes. While exploring these issues, my supervisor
suggested that I might sensitively remind Tracey about the therapy frame, and alert
her to the end of a session 5 or 10 minutes earlier. I was able to do this without
creating an impact on the therapeutic relationship, and maintaining the therapeutic
frame.
Disjunction
During one of the sessions, Tracey stated "I had never learnt to protect myself from
angry people" and then reported calling the police on the pretext of her husband
getting angry with her – this was something she used to do but had not done for the
last two years. I became obviously upset with Tracey, and I asked if the police had at
any time asked her to leave her husband. Tracey reacted to my becoming judgemental
of her and became silent. I noticed that I was becoming angry with her husband and
could not contain it, but might have also been wondering why she had not left her
husband, why she was enduring so much pain. I recognised my countertransference in
supervision and was helped to reflect apologetically on this with Tracey, repairing the
disjunction, which I created, but reflected on, acknowledged and proceeded, noting
that the therapeutic relationship was more enhanced.
In supervision, I learned that traumatic memories could intrude from time to
time and influence behaviour in the here-and-now as a result of repetition of
unconscious traumatic material. The therapist’s non-judgemental attitude and
28

empathetic responsiveness must be consistent so that the patient feels safe to talk
about their most shameful experiences.20
Though Tracey initially was full of self-blame, she gradually explained her
reason for not visiting her father before his death, which followed a confrontation
with him when he made an offering of money for sex with her niece. Tracey’s father
also confessed sexually abusing her half-sister. Tracey said, “What I learnt from my
father is that your mother is not meeting my needs that’s why I had to do what I did to
your sister. When Tracey asked him if he had also abused her, he questioned her
rather than answering, saying, “what are your memories?” This response made her
believe that she had also been sexually abused but had no memories.
We talked about Tracey’s social isolation as she kept mentioning, "I don't have
friends, I don't like to go out, I don't have the energy", “I am a home pigeon ”and also
mentioned about spending most of her time “watching TV and documentaries.” We
explored her interests and hobbies and ways to improve her social connectedness.
The ethical issue of personal disclosure
Tracey continued to eagerly talk in therapy and on one occasion she asked me about
my zodiac sign, and realised that it was similar to hers, - this, in turn, reinforced her
faith in me as a therapist. Though hesitant to disclose my personal details, in
supervision my supervisor discussed therapeutic disclosure and considering
beneficence and non-maleficence when the patient enquires about personal
disclosure.21 Personal disclosure must benefit the patient and not be done in the
interest of the therapist.
29

We had during these sessions achieved what Robert Hobson called “aloneness-
togetherness” which would help the emergence of a particular kind of consciousness
called “self”.14
Middle Phase-sessions (16 -26)
Our therapy framework changed out of necessity, due to my sudden repositioning to a
rural placement. I was distressed about not only breaking Tracey’s trust but
potentially losing her, an ideal therapy patient. After a discussion with my supervisor,
I explained this to Tracey and proposed that we continue therapy with a mixture of
mostly face-to face sessions whenever I was able to commute and occasionally
through video-conferencing. Tracey took an interest in video conferencing and she
agreed. I received authorisation from the RANZCP and adhered to the standards of
videoconferencing, which has been found to promote fairness of access and increased
levels of patient satisfaction.22
I formed a liaison with the community mental health team who offered to
review Tracey after the videoconference sessions, and I was able to continue the
therapy even after my relocation.
Transference and Countertransference
I questioned whether Tracey said yes to videoconferencing sessions due to her
habitual desire to please and accommodate, with in the transference. I enquired her if
she had agreed to avoid disappointing me, and Tracey stated “I got connection with
you, therapy is a safe place which supports me, gives me feedback and
encouragement to try things, helps to deal with my husband and day to day life". I felt
relaxed that Tracey made an independent decision but her idealising and child-like
dependency often left me feeling like a mother to her, and I had to stop myself from
30

becoming overprotective or from giving excessive advice. Supervision helped me to
share these countertransference feelings with Tracey, and it facilitated dyadic
exploration of her childhood and sense of yearning for her mother.23
The theme of the therapy sessions shifted from negative to positive themes. She was
proud of abstaining from illicit substances and alcohol use, and achieving honours in
her accountancy course. She talked about the piano as her passion and she expressed
fulfilment in recognising her strengths. There was a positive shift in her attitudes
towards interpersonal relationships. However, her frustrations about her husband
continued though infrequently referred to.
Tracey: not much improved with Chris sadly
Therapist: Not much sadly (emphasis is given to word sadly)
Tracey: Well, except I –I think, I am realising that I am arguing less with Chris….I
think there is some change.
Therapist: Hmm
Tracey:He also helps me as long as I am not attacking him
Therapist: Aha
She continued “I know I am taking a lot of things out on my husband” and “I am
getting more peaceful moments; I am getting to like my husband.” This provided
evidence of change.
I was aware that this was the most contentious and sensitive issue currently for
Tracey, so my responses were tentative and almost like the protoconversation were
monosyllabic and in sync with hers. According to Robert Hobson (1985), these
31

"minute particulars" where the therapist’s response is coupled with the patient’s, are
crucial in the Conversational Model.14
Emerging Self-reflective capacity (SRC)
I did not confront Tracey about her relationship with her husband, and as therapy
proceeded it was evident that she was developing a capacity to reflect on her
behaviour and attitudes towards others, particularly her husband. SRC is the desired
outcome in the Conversational Model rather than the development of Insight which is
regarded more as intellectual than emotional.20
Fear of Loss
One notable theme that emerged during the sessions was her fear of loss of loved
ones. She talked about being upset by her daughter going for cosmetic nose and breast
surgery and was fearful for her. Following supervision, I explored the losses that
Tracey had suffered, and she became quite emotional while talking about the death of
her younger brother from diphtheria, her half-sister by hanging and also grieved about
her parents. There were mixed feelings of anger, guilt and shame. She felt safe to
grieve and talk about her many losses without being judged. I noticed that she still
avoided talking about her son Jimmy.
Improved Relationships
In one session Tracey reported that her daughter-in-law was admitted to ICU being
affected with a lung infection. However, unlike previously, instead of fragmenting,
she maintained an optimistic attitude and also demonstrated a willingness to provide
care and support to her grandchildren and son. She attributed this improvement in her
mental wellbeing to the therapy sessions, which also enhanced her relationship with
her daughter-in-law. Hence, the therapy sessions were able to address the feelings of
32

isolation and alienation successfully and encouraged Tracey to experience fondness
with her family members, by identifying their need for her emotional support.
On Tracey’s request, her daughter and husband were invited to her individual
session. While her daughter acknowledged benefitting from the session, and was able
to change her perceptions of her mother as “always help seeking via therapy”, her
husband remained unchanged and maintained his aggressive and rigid attitude toward
her.
Tracey revived her interest in participating in hobbies like playing the piano,
watching movies and swimming. She also reported researching different aspects of
music thus reinforcing her zeal for life. She was developing a sense of agency and a
healthier sense of self.
Late Phase - Sessions 27-37
Statements like “I haven’t been so angry” and “I have been more steady”
suggested improvement and enhanced mental health. She re-established contact with
her siblings and continued to attend AA group. On returning from my rural
placement, she started to talk about her son's Jimmy death due to an accidental
heroine overdose, and described how adorable he was. Statements like “I was not a
good parent, I couldn’t save my son”… "I have a lot of sadness for my son, I avoided
the pain by keeping myself busy in the job and studying" showed her guilt, shame and
pain but this was acknowledged quite differently from earlier – she was more in touch
with the reality of her loss. She reported for the first time in her life she talked about
her son and cried.
New emerging themes
33

Tracey talked about her son John’s recent disclosure of being physically abused as a
child by her husband. Tracey said she was not aware of any physical abuse towards
her children, but later on, confided being abusive towards them under the influence of
alcohol. She expressed appropriate guilt and remorse for her failings but was
determined to do better. In another session, she was particularly distressed after
knowing that her brother, who had been molested at a young age, sexually abused his
own daughter. Tracey was able to express emotion appropriately and did not become
overwhelmed as she did initially.
Once again my apprehension of disclosing personal information arose when
Tracey repetitively asked me about my family. Supervision supported me. I noticed
that Tracey found it helpful even if I only mentioned having kids of her
granddaughter’s age without any further details.
Self Reflective Capacity
Increasing self- awareness, widening of consciousness and reflective capacity helped
her deal with traumatic memories in a more mature way – acknowledging things that
had happened, taking responsibility, but also having compassion for herself. From a
state of emotional alienation, one could say she had experienced a level of “intimacy”
in the therapeutic relationship - “aloneness-togetherness” which had enabled her to
discuss and process her past traumatic experiences and finally “integrate” them into
her personal history as “lived experiences” that were hers but were no longer causing
her unbearable distress.20
On review, she confirmed that she was able to confront things directly, instead of
avoiding them or isolating herself. She affirmed, “I get overwhelmed with myself and
my feelings and therapy helps me”. She reported being able to be more compassionate
34

and kind towards her children. She reported improvement in her sleep; she made
efforts to go out for coffee with friends as opposed to being socially isolated and
started going to dinner and shopping with her husband. She also discussed her plans
to go on a cruise and showed more interest in spending time with her grandchildren
and children.
Termination (38-42)
I was anxious about Tracey’s reaction to termination as I had only one planned break
and Tracey had taken one session off when she was sick, so there were minimum
breaks of any length. Tracey was reminded in a timely manner that therapy was soon
coming to an end and we revisited her goals. We agreed that initial set goals had been
achieved, as evident by improve interpersonal relationship, reduction in symptoms,
improve quality of life and enhanced coping skills. After further discussion with my
psychotherapy supervisor, CMHT and Tracey, it was mutually decided to terminate.
CMHT case manager offered to provide ongoing support. Tracey was anxious but
keen to practise the skills, which she learnt in therapy and was happy with the follow-
up plan. She was aware that she could request for help if need arises in future. We
agreed to have two final sessions to enable closure.
In the 42nd session I provided Tracey with a brief summary of my experience
of working with her. I appreciated her politeness, flexibility, punctuality, and
motivation to change. Tracey expressed gratitude at not being judged and for my
patience and care. Excerpts from her statements like “you didn’t let me down”, “you
have given me hope”, "I got more insight, I can see little clearer" and “I was amazed
by you commuting to see me” “you were consistent” suggested that I had done a
“good-enough” job in providing psychotherapy to Tracey. Though she was sad at
ending “my heart is little bit breaking ", she realised that it was on the terms of the
35

contract and accepted it with a good heart. I felt sad, but relieved that Tracey didn’t
feel abandoned. I was assured that her help seeking nature and this positive
therapeutic experience would encourage her to seek therapy in future if needed.
Reformulation
Tracey was a 66-year-old Asian female who presented with symptoms consistent with
persistent depressive disorder and borderline personality disorder predisposed by
insecure attachment, early childhood trauma and genetic susceptibility. Her symptoms
were maintained by interpersonal difficulties with her husband and significant others
and multiple losses in her life.
The Conversation Model helped to frame Trace’s presentation from a different
perspective, one primarily related to a disorder of self, stemming from traumatic early
life experiences. This destabilised self hindered her capacity to maintain meaningful
relationships, led to poor self-image, emotional dysregulation and her increased
reliance on a false self to connect with others. The psychotherapy was directed
towards restoring the disrupted sense of self.
By providing Tracey with a safe and secure therapeutic relationship, I was able to
explore details of the invalidating, harsh and unsafe atmosphere she faced while
growing up with a constant fear of rejection and abandonment by her primary
caregivers. Frightening and consistently invalidating care givers deprived her of the
secure base and hindered the development of her sense of self. She recognised that
her concept of self was reliant upon reactions from those around her. Her sensitivity
to criticism and poor sense of self prevented her from taking initiatives in life and
resulted in poor interpersonal relationships and social isolation.
36

I speculated that Tracey protected herself via pathological accommodation.24 For
example, she accommodated as a child to please her parents, and this continued later
in life in her use of sex to appease her husband. Pathological accommodation is
commonly seen when the parent-child relationship is dominated by fear, and child
pathologically acquiesces with his/her parents. Another psychodynamic process noted
during therapy was her tendency to fragment and dissociate under stress, a ubiquitous
presentation seen in patients with BPD .25
Due to early traumatic experiences Tracey's resilience against stress was hindered,
predisposing her to break down psychologically in times of crisis. She was
overwhelmed by cumulative losses in her life and the strained relationship with her
husband which forced traumatic intra-psychic components of the relationship with
her parents to frequenly resurface. As a therapist using the principles of the
Conversational Model (coupling, amplification and representation) and "minute
particulars", I helped Tracey to identify and integrate fragmented traumatic memories
and make positive changes in her relationship with Chris.14
Her reflective capacity emerged early in our sessions and improved as therapy
progressed. Her fear of abandonment improved as manifested by her ability to
maintain integrity when her daughter-in-law was in the ICU, and her daughter
underwent cosmetic surgery. Within our safe therapeutic relationship, Tracey was
able to discuss her guilt and shame of not being a “good enough” mother. At the
termination, her feelings of being an inadequate mother decreased, and there was a
significant improvement in both her functional capacity and interpersonal
relationships.
37

As therapy progressed, I realised how her mistrust in others, low self-esteem as well
as shame and guilt of being a bad mother could also be conceptualised as
manifestations of a failure to progress through the normal Eriksonian developmental
trajectories, thereby representing an alternative, longitudinal understanding of
Tracey’s psychopathology. It was through the stable and holding atmosphere of
therapy in which Tracey was not compelled to pathologically please that she found
the opportunity to achieve a healthy equilibrium between ego integrity and despair at
this Eriksonian stage of her life26.
Positively, the perceived progress in the therapy, enhanced ability to form a
therapeutic relationship, her improved reflective capacity, and her strong desire for
positive change made me optimistic that Tracey’s improvements would continue
after termination of therapy.
Supervision
I received weekly individual face-to-face supervision interspersed with few telephone
supervisions from a senior RANZCP accredited psychotherapy supervisor who was
trained in the Conversational Model. Supervision provided me with a safe and
professionally reflective space for learning and practising psychodynamic
psychotherapy. With the guidance of my supervisor, I succeeded through patient
selection, navigating the frame, therapy process and termination. I presented therapy
notes from previous sessions, and together we listened to audiotapes, which is an
essential part of training in the Conversational Model. I was definitely challenged as a
novice therapist not knowing what to expect and how to react in early sessions. My
supervisor understood my anxiety and remained non -judgemental of my errors and
helped me to recognise unconscious dynamics in the transference and
countertransference. Supervision also enabled me to deal with the ethical issues of
38

self-disclosure. We discussed boundary violation and crossing and considering
beneficence /maleficence before any attempted disclosure21.
Researchers have found telephone supervision to be reliable, affordable and
easily accessible.27 I personally found no difference with supervision over the
telephone. It would have been challenging if I was in group supervision instead of an
individual session. I felt that supervision contained me and I was able to provide the
ongoing therapy sessions with Tracey, despite my unplanned rural placement.
Communication and liaison
Prior to the therapy commencement, I was personally introduced to Tracey by the
DBT therapist, and after obtaining her consent I collaborated with the GP and local
CMHT psychiatrist. During the rural placement, there was an ongoing liaison with a
local CMHT psychiatrist, case manager and supervisor as well. At the end of the
therapy, I updated the CMHT psychiatrist, case manager and GP by providing verbal
handover and discharge letter.
DISCUSSION
Reflection on the mode of therapy
As discussed in the management section, considering Tracey’s long-lasting
difficulties and early traumatic experiences ,the Conversation Model deemed
appropriate as it provided a safe therapeutic space and relationship to gradually
explore these issues.
Theoretical aspects of the mode of therapy
39

The Conversational Model (CM) was named by Robert Hobson and was developed
out of work with patients who were considered "unanalysable". The work began in
1965 with a focus on "minute particulars" by the use of audiotapes to study the
therapeutic conversation14.Australian psychiatrist Dr Russell Meares had further
refined CM by integrating neuroscientific developments.
Researches have found CM as an efficient, cost-effective and highly beneficial in the
treatment of Borderline personality disorder8,11,28,29. It is also found effective in the
treatment of resistant depression, other personality disorders, somatoform and anxiety
disorders, treatment-resistant schizophrenia30and complex trauma31.
The Conversational Model is a phase-model. The central task of psychotherapy is to
potentiate the emergence and amplification of the dualistic form of consciousness that
William James called the “self”. This arises in the context of a particular kind of
relatedness which is mediated through conversation in the safety of the therapeutic
relationship.This relationship is considered to be a vital part of successful
psychotherapy of all theoretical orientations19. The second therapeutic objective is to
identify the intrusion of traumatic memories in order to integrate them into an
ordinary, ongoing dualistic consciousness and to process them.
Therapeutic process and Significance for the patient
The strong therapeutic alliance which we developed helped Tracey bring about a
better sense of self. By the end of the initial sessions, I was able to foster a form of
relatedness, which Hobson called "aloneness togetherness" which was seen as a
central aim of the therapy. Hobson's aloneness togetherness "is a state in which, while
40

with another, one's own world is retained, and while alone, one is not afflicted with
the pain of isolation"14.
Therapy provided Tracey with a safe place to grieve about multiple unresolved losses
in her life. She was able to talk about her flaws as a mother and with empathic enquiry
and mirroring provided by the therapist,she became more compassionate towards
herself. There was an improvement in her fear of losses and abandonment manifested
by being optimistic when her daughter in law was in the hospital. She was able to
differentiate between her internal psychological process and external reality. The
timely identification of transference and countertransference and adequate repair
work of therapeutic disjunctions provided an opportunity for therapeutic growth.
Further more,Psychodynamic psychotherapy invigorated her sense of self boosted by
the positive affirmation and validation provided by the therapist. It refreshed her
interpersonal relationships, and she was able to spend some enjoyable time with her
husband which she had not done for a while. She started to relate to herself and other
family members maturely and desirably. Despite there were no changes in her life
circumstances, Therapy helped to change Tracey's view into a more positive sense. It
also drifted her negative cognitions towards optimism. Lastly, she didn't feel abandon
at the end of therapy.
My learning as a trainee
As a trainee, this was my first experience of providing long term psychodynamic
psychotherapy. The psychotherapy sessions were essential for the completion of my
training but also improved my knowledge of psychodynamic psychotherapy. It further
taught me a model of therapy implemented in Complex Trauma sufferers. I
41

understood the importance of fellow feeling and how a therapist through consistency,
empathetic validation and being available help patient to develop reflective capacity.
Although my sudden rural placement made me nervous about the interruption of the
sessions with Tracey, my consistency, her flexibility, supervision by a senior
psychotherapist and incorporation of a total of 6 sessions by video conferencing made
it possible for therapy to continue. The main concern with video conferencing was the
perceived difficulty in developing an effective therapeutic relationship in the absence
of non-verbal cues32. In my case, the therapeutic alliance was already established. It
would have been difficult if I needed to use video conferencing in the initial sessions
or if all the sessions were by video conferencing as verbal and non-verbal cues are a
very important part of the Conversation Model. My videoconferencing sessions were
interspersed with face-to-face sessions, which allowed me to pick up on minute
particulars and provided physical proximity which are essential for ongoing rapport32.
Though on a couple of occasions I wished I would have been physically present with
Tracey to comfort her when she was upset. In summary, I enjoyed the challenging but
interesting journey with Tracey and my collaboration with her made me confidant to
use psychodynamic concepts in my day to day clinical practise.
REFERENCES:
1. Mathew RJ, Wilson WH, Blazer DG, George LK. Psychiatric disorders in
adult children of alcoholics: Data from the Epidemiologic Catchment Area Project.
The American journal of psychiatry 1993.
42

2. Benjet C, Borges G, Medina-Mora ME. Chronic childhood adversity and onset
of psychopathology during three life stages: childhood, adolescence and adulthood.
Journal of psychiatric research 2010; 44(11): 732-40.
3. Bhugra D, Becker MA. Migration, cultural bereavement and cultural identity.
World psychiatry 2005; 4(1): 18.
4. Association AP. Diagnostic and statistical manual of mental disorders (DSM-
5®): American Psychiatric Pub; 2013.
5. Alexander J, Cheng YH, Choudhary J, Dinesh A. Phentermine (Duromine)
precipitated psychosis. Australian and New Zealand Journal of Psychiatry 2011;
45(8): 684-5.
6. Bloch S. Assessment of patients for psychotherapy. The British Journal of
Psychiatry 1979; 135(3): 193-208.
7. Cuijpers P, Geraedts AS, van Oppen P, Andersson G, Markowitz JC, van
Straten A. Interpersonal psychotherapy for depression: a meta-analysis. American
Journal of Psychiatry 2011; 168(6): 581-92.
8. Korner A, Gerull F, Meares R, Stevenson J. Borderline personality disorder
treated with the conversational model: a replication study. Comprehensive Psychiatry
2006; 47(5): 406-11.
9. Levy KN, Ehrenthal JC, Yeomans FE, Caligor E. The efficacy of
psychotherapy: focus on psychodynamic psychotherapy as an example. Psychodyn
2014; 42(3): 377-421.
10. Meares R, Stevenson J, Comerford A. Psychotherapy with borderline patients:
I. A comparison between treated and untreated cohorts. Aust N Z J Psychiatry 1999;
33(4): 467-72; discussion 78-81.
11. Stevenson J, Meares R, D'angelo R. Five-year outcome of outpatient
psychotherapy with borderline patients. Psychological Medicine 2005; 35(1): 79-87.
12. Shedler J. The efficacy of psychodynamic psychotherapy. American
psychologist 2010; 65(2): 98.
13. Gaskin C. The effectiveness of psychodynamic psychotherapy: A systematic
review of recent international and Australian research. Melbourne: Psychotherapy &
Counselling Federation of Australia 2012.
14. Meares R. The conversational model: An outline. American Journal of
Psychotherapy 2004; 58(1): 51-66.
15. Berk M, Parker G. The Elephant on the Couch: Side-Effects of Psychotherapy.
Aust N Z J Psychiatry 2009; 43(9): 787-94.
16. Jacob K. Recovery model of mental illness: A complementary approach to
psychiatric care. Indian journal of psychological medicine 2015; 37(2): 117.
17. Rogers CR. A way of being: Houghton Mifflin Harcourt; 1995.
18. Holmes J. The search for the secure base: Attachment theory and
psychotherapy: Routledge; 2014.
19. Gelso CJ, Palma B, Bhatia A. Attachment theory as a guide to understanding
and working with transference and the real relationship in psychotherapy. Journal of
clinical psychology 2013; 69(11): 1160-71.
20. Meares R. Borderline personality disorder and the conversational model: A
clinician's manual: WW Norton & Company; 2012.
21. Gutheil TG. Ethical aspects of self-disclosure in psychotherapy. The
Psychiatric Times 2010; 27(5): 39-41.
22. Chakrabarti S. Usefulness of telepsychiatry: A critical evaluation of
videoconferencing-based approaches. World journal of psychiatry 2015; 5(3): 286.
43

23. Gedo PM. Transference-countertransference repetitions of traumatic affects.
Bulletin of the Menninger Clinic 2013; 77(2): 161-77.
24. Brandchaft B. Systems of pathological accommodation and change in
analysis. Psychoanalytic Psychology 2007; 24(4): 667.
25. Korzekwa MI, Dell PF, Links PS, Thabane L, Fougere P. Dissociation in
borderline personality disorder: A detailed look. Journal of Trauma & Dissociation
2009; 10(3): 346-67.
26. Meares R. The metaphor of play: Origin and breakdown of personal being:
Routledge; 2005.
27. Deane FP, Gonsalvez C, Blackman R, Saffioti D, Andresen R. Issues in the
Development of e‐supervision in Professional Psychology: A Review. Australian
Psychologist 2015; 50(3): 241-7.
28. Stoffers JM, Vollm BA, Rucker G, Timmer A, Huband N, Lieb K.
Psychological therapies for people with borderline personality disorder. [Review].
2012; 1(8): Cd005652.
29. Haliburn J, Stevenson J, Gerull F. A university psychotherapy training
program in a psychiatric hospital: 25 years of the conversational model in the
treatment of patients with borderline personality disorder. Australasian Psychiatry
2009; 17(1): 25-8.
30. Davenport S, Hobson R, Margison F. Treatment development in
psychodynamic interpersonal psychotherapy (Hobson's ‘Conversational Model’) for
chronic treatment resistant schizophrenia: Two single case studies. British Journal of
Psychotherapy 2000; 16(3): 287-302.
31. Korner A, McLean L. Conversational model psychotherapy. Australasian
Psychiatry 2017; 25(3): 219-21.
32. Glueck D, Myers K, Turvey C. Establishing therapeutic rapport in telemental
health. Telemental health: Clinical, technical and administrative foundations for
evidence-based practice 2013: 29-46.
44