Psychotherapy & Liaison Skills
Background and Motivation: People with borderline personality disorder rely upon core defense structures such as primitive denial, splitting, projection, projective identification, and idealization/devaluation; however, everyone, at times, may employ maladaptive defenses in certain stressful situations. Clinical systems, especially the inpatient hospital, are inherently stressful environments. Under the (sometimes) extreme chaos generated by complex, frustrating, and anger-inducing clinical situations, “normal” people operating within these systems, including but not limited to patients, their family members, hospital staff, and administrators, will use these primitive defenses. During such moments the psychiatrist may be pulled into a dynamic black hole of intense emotion, particularly anger, or may experience emotions alien to their norm. These situations may contribute to feelings of frustration and helplessness in the psychiatrist and lead to impulses to act on one’s anger (fight) or to flee the situation (flight). CL psychiatrists can feel more empowered at managing these problematic encounters through the use of psychotherapeutic skills typically employed in the dyadic work with borderline patients.
Approach: In this interactive workshop, we will strive to understand how primitive defenses operate in individuals with primary psychopathology, and extend that understanding to how primitive defenses can manifest when otherwise healthy individuals in the inpatient hospital system come under pronounced pressure and anxiety. We will begin with a discussion of defense mechanisms. This will be followed by a discussion of common problematic clinical scenarios that contribute to systemic anxiety and activation of primitive defenses. We will review clues that can help the CL psychiatrist identify when primitive defenses are activated and explore potential countertransference in these situations. Using interactive role-play with the audience, we will suggest strategies for maintaining one’s equilibrium when faced with these defenses, with a particular focus on how to adapt psychotherapeutic interventions to encounters involving non-patients.
Product: For the first 20 minutes of the session, Dr. Muskin will provide didactic instruction about primitive defense mechanisms. Subsequently, Dr. Critchfield will spend 15 minutes presenting clinical vignettes that demonstrate the applicability of these general principles to common scenarios faced by consultation-liaison psychiatrists in the inpatient medical hospital. Over the next hour, Drs. Garza and Nash will role-play these scenarios with volunteers from the audience. The include scenarios such as the enraged hospital administrator, the accusatory departmental administrator, the hostile primary care team physician, and the departmental chair who has received a complaint about the CL psychiatrist. In a highly experiential way attendees will have an opportunity to struggle through these situations, ultimately developing or honing their abilities to identify practical solutions to challenging encounters through the use of applied psychodynamic psychotherapy principles. Opportunities for real-time discussion with questions and answers from the larger audience will be built into this experiential model.