Description of my philosophy of care as it relates to mental health problems, chemical dependency, and addictive disorders.  

Of all the forms of therapy, the psychoanalytically-oriented approach is founded upon the most extensive, inclusive, and comprehensive system of psychology since it encompasses one's inner experience and outer behavior, one's biological nature and social role, how one functions as an individual and how one functions as a member of a group.  By enabling the patient to understand how his/her symptoms and behavior represent derivatives of unconscious conflicts, this theoretical approach permits the patient to make rational choices instead of responding to mere instinct.

With this theoretical framework in mind, regardless of the presenting problem (general problems of living, acute emotional reactions, and/or chemical dependency-addictions in general), the focus of the initial few sessions is to provide the patient with hope, and attempt to develop a therapeutic alliance.  When patients are heard and feel understood, perhaps for the first time in their lives, it allows them to explore their motives from a different perspective and learn more appropriate problem solving and communication skills.  Behavioral interventions may also be implemented to render concrete and visible measures of change.

While the traditional long-term approach produces obvious benefits, sometimes financial challenges will not allow for the cost of intensive treatment.  Thus, by employing brief forms of dynamic therapy (5 to 10 sessions), it is possible to help the patient enhance coping skills and experience symptom relief within a shorter period of time.  And the added gain of understanding the antecedents of the problem(s), aids in the prevention of relapse.

When individuals present with homicidal or suicidal ideation (or are in need of detox), the need for hospitalization is assessed.  Referrals to inpatient facilities are made when the patient presents with a clear danger to him/herself, or when intensive inpatient measures are needed for chemical dependency rehabilitation.  When possible, an attempt is made to help patients remain in their normal environment by making verbal contracts and maintaining daily telephone contact (or office visits) until the crisis has passed. This approach, I believe, is in keeping with a WELLNESS model versus a Pathological model, and promotes a sense of empowerment and development of a healthier self esteem.  As crisis situations arise, arrangements are made to talk with patients more frequently, or schedule additional sessions.  A psychiatric consultation is also sought when there is any question about medication and/or to rule out an underlying medical problem which may be contributing to the patient's difficulties.

Literature suggests that simply providing psychotherapy for chemical dependency or any sort of addictive behavior is not as effective as encouraging participation in peer support groups ( i.e., AA, NA, GA, OA) or process/therapy group. Therefore, I encourage patients to make a commitment to attend a group of their choice in conjunction with psychotherapy.  As most individuals with addiction problems rely on a substance or object to assuage anxiety, the goal is to help patients identify the triggers that drive the compulsion(s), and help them find more effective ways of dealing with life's stressors.  

Description of my perspective on the etiology of mental health problems,  chemical dependency, and addictive disorders. 

Having trained in an institution which was particularly sensitive to cultural diversity, it is difficult to give a global statement on the etiology of mental health challenges, chemical dependency, and addictive disorders.  However, although individuals originate from very diverse backgrounds, it is likely to assume that each person brings with him/her unresolved baggage from early life regardless of culture, religious expression, or sexual orientation.  And it is these unresolved issues which inhibit effective coping skills, effect self esteem, and cause conflicts in patient's lives and relationships.

Thus, from a psychodynamic perspective, patients can be understood as appearing to recreate and relive unresolved issues from their past. By aiding them in the quest to identify feeling states and helping them explore different modes of expression, the goal is to help them develop more appropriate coping, problem-solving, communication, and assertiveness skills.  While the traditional approach would dictate years of therapy, short-term work can provide patients with symptom relief and a better understanding of self and other, regardless of cultural influence.  Of course, patients are offered the opportunity to continue the therapy process at their own expense (versus the insurance company's expense) when benefits have been exhausted.

From a sociological/environmental perspective, maladaptive responses to psychosocial norms may be seen as a means of attempting to cope with ego dystonic situations (i.e., peer pressures at work or in their personal lives).  Short-term goal-oriented therapy is usually effective since it can provide a road map for implementing change, and provide patient's with effective tools to continue the process following termination of therapy.  If there is evidence of significant anxiety and/or depression, patients are referred for a psychiatric/medication evaluation.  When prescribed, medication is generally only needed on a short-term basis (crisis), because as coping skills increase the dysphoric mood abates, the patient is better able to manage their lives.

When a particular disorder is displayed in other family members, it suggests that there may be a biological component (e.g., bipolar disorder, depression, alcoholism, etc).  And it is this biological propensity that may trigger an emotional upset (or binge) when previously effective coping mechanisms falter.  Supportive therapy, in conjunction with medication may help patients maintain ADL's (Activities of Daily Living) and lead productive lives. 

In my view, hospitalization should be considered as a last resort for any disorder because removing a patient from his/her normal environment (when unnecessary) may reinforce the notion that he/she is incapable of taking care of him/herself.  Of course, if the patient is a danger to self or others, or in need of detox, the appropriate referral is made.  And if patients require treatment from a psychiatrist, I inform that patient of the importance of "team work" and request his/her permission via consent to confer with the psychiatrist on a regular basis regarding the patient's treatment.

Karen E. Engebretsen PsyD, LLC
Florida Licensed Psychologist, FL Lic: PY0005409
Copyright 2000-2010