Exposición de los datos cuantitativos e interpretación

You should read these guidelines in conjunction with the general guidelines for Case Reports, as these are supplementary rather than replacement guidelines, and we have not addressed every section. If you are working in a specialist psychotherapy department your client will probably already have been through a preliminary assessment by another mental health worker prior to referral to the department, and may well have been assessed by the team before the referral to you. In this case, using the information from the assessment and your own experience of the initial session/s with the client, you should write up your assessment, formulation and treatment aims/action plan before proceeding to intervention.

If you are working in a generic setting (e.g. primary care or a CMHT) it is more likely that the initial assessment will be a general psychological assessment rather than specifically a psychodynamic assessment. If you conduct a general assessment for therapy following which it is agreed with your supervisor to use a psychodynamic approach, you should briefly describe the initial assessment and then make a brief initial formulation with an action plan to undertake a psychodynamic assessment (as described below); this should be followed by a psychodynamic formulation that forms the basis for treatment aims and intervention.

Stylistic Comment:

It is common practice in many psychotherapy departments to refer to the people who use the service as ‘patients’. In your case report use the form of reference used in the department in which you have been working, but explain why you have done so if you use the term ‘patient’.

Theoretical Framework:

When writing about a piece of psychodynamic work you need to make explicit whose theories are guiding your work at any given stage of the report eg Freud, Klein, Winnicott, Bowlby, Jung, Bion. Psychodynamic thinking is quite divergent in some areas and it is important to be clear about the origin of the theoretical perspective that has shaped your thinking and intervention.

Assessment:

Assessment in psychodynamic work is an ongoing process throughout therapy, similar to system working, so that there is sometimes not the clear demarcation between assessment, formulation and intervention that there usually is in other approaches like CBT. Nevertheless, there is a period of time at the beginning of therapy when there is an assessment of the client’s suitability to work psychodynamically in conjunction with an assessment of whether the presenting problem is best suited to a psychodynamic intervention.

It may not be possible to assess the client yourself, but if you have not conducted the assessment you do need to demonstrate that there was a process of assessment, and describe the major issues that were addressed in that assessment. In particular you need to account for why this client was deemed suitable for psychodynamic work rather than an alternate intervention. You will need to address suitability criteria (e.g. ego strength) and comment on the extent to which they were considered in the assessment by the person who referred the client to you.

Whether or not you conduct the formal initial assessment, it is important in a psychodynamic case report to describe your initial impression of the client and how you experienced her/him on first meeting. This might include physical appearance, dress and general care, deportment, mode of speech and body language. All this information provides an indication of how the client relates to him/herself and the structure of his/her internal object relationships. Where clients have already been engaged within mental health teams, and are perhaps considered “complex”, there is often a wealth of

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information about the client contained in previous notes and in relation to their attachment history with the team. Some thought might be given as to whether this has influenced you in terms of your initial impressions (e.g. did you read the notes or decide to wait for the first meeting? Did your impression of the client match previous discussions within the team or from people who had previously worked with them?). You might want to reflect on such relationships with the team as part of your dynamic formulation.

Beyond assessing for suitability the primary function of a psychodynamic assessment is to begin the process of understanding the core conflict/s that the client is struggling with (but which may not have been identified as the presenting problem). Information that will assist in determining an initial formulation of the client’s core conflict/s include: an account of the presenting problem/s; a developmental history; an account of current relationships; information from the transference and countertransference.

You need to place specific emphasis on the client’s developmental history, with particular reference to:

1. The quality of relationships with important others (primary carers, usually parents);

2. Any disruptions in early relationships (e.g. hospitalisation, going into care homes, fostering/adoption);

3. Place in the family (eldest, youngest etc) and quality of relationship with siblings and other family members as a child;

4. Social relationships (e.g. at school);

5. Early trauma or history of abuse (to include sexual, physical and verbal as well as early neglect).

6. (If your client cannot remember his/her childhood you should discuss the significance of this in your report.)

Similarly you need to refer to the client’s current relationships with family, school or work colleagues, social relationships, and any previous experience of therapy in order to assess current functioning. It is useful to include an account of any recurrent dreams your client reports since they may give important indications about preconscious or unconscious preoccupations. Similarly early memories can provide useful information about early object relationships and the client’s experience of self. Your assessment may also include an assessment of the client’s defensive structure.

Information from the transference and counter-transference refers respectively to the way in which the client relates to and experiences you, and the feelings and thoughts that you have in response to him/her. In describing the counter-transference you need to be careful to distinguish between those reflections that are based on your development as a therapist and your specific reactions to your client based on his/her unconscious communication.

Although psychotherapy departments may not use standardised tests such as the BDI, some do use psychodynamic measures of current functioning or routine evaluation measures such as CORE. If you do not use or have access to any standardised assessment measures to collect baseline data you need to acknowledge this and explain why you have not included this information.

It is also essential that you reflect upon issues of risk, especially if you are undertaking dynamic work with people who have histories of substance misuse or who have taken overdoses. You will also need

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to consider the risk management plan in the context of a team approach for clients who have complex psychiatric needs.

Formulation:

As with other Case Reports, the formulation must be based in theory and it must relate to the planned intervention. So, for example, if you have a client who has difficulties in coping with separation you need to refer to the psychodynamic literature on separation in order to ground your formulation in theory.

A psychodynamic formulation should, if possible, include a description of the presenting problem and the client’s core conflict/s, the developmental roots of the difficulty, a hypothesis of how the client’s internal object relationships currently function, and how these relate to the presenting problem. Your formulation should, again if possible, include reference to how a core conflict is represented in the transference relationship, early relationships and current relationships (see Molnos, 1995).

Like assessment, formulation in psychodynamic work is an ongoing process, and it is likely that you will be unable to include all the above information at the formulation stage, but you should indicate you are aware that this information is necessary to make a comprehensive formulation.

Treatment Aims/Action Plan:

Your action plan in a psychodynamic case report will describe the piece of work you intend to undertake with your client. So, taking the example used above, if separation difficulties have been identified as the core conflict, the action plan should demonstrate how you intend to address this issue. This may be through using the transference relationship to address issues of separation as they arise naturally in the work (eg at the end of the session or the end of therapy), and/or by making links between past losses and present difficulties in separating from people other than the therapist. The treatment aims in this case might include the aim that the client would be able to cope better with a forthcoming separation, or be able to work through the separation from you at the end of therapy. As in other Case Reports you will need to support your action plan using the literature.

Intervention:

Before reading this section, refer to the general instructions for writing Case Reports.

There is an important difference between interventions that are psychodynamically informed and those which use psychodynamic techniques during the intervention phase.

Interventions that are psychodynamically informed are those in which psychodynamic principles guide the formulation and underpin the choice of intervention. The intervention itself is likely to be structured, perhaps using a variety of non-psychodynamic techniques to attain therapeutic goals. These interventions can be written up according to the general case report guidelines, while being cognisant of any additional guidelines below which may be helpful.

Interventions which use psychodynamic techniques may be structured or unstructured. They are likely to be structured if you are undertaking a piece of brief therapy, and may be unstructured if you are undertaking a longer piece of therapy (e.g. on a year-long specialist placement). You need to explain why you used a structured or unstructured approach and you should explain how a session was conducted and describe and justify the techniques you used (e.g. free association) by linking them to the literature.

In describing the intervention it is important to first refer to the establishment of the therapeutic space and the use your client made of it before discussing the body of the work. You should also discuss the creation of a therapeutic alliance, and whether there were difficulties in creating one. You should give examples of how the transference and countertransference was manifest in the work, as well as how

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the client coped with the work. It is particularly helpful in a psychodynamic case report to illustrate technique or theory with a short transcript from therapy. However, do not use this too heavily as it is expensive on words!

Additional information which emerges in the course of the intervention and leads to a revision in your formulation and treatment aims or action plan should be included in this section. Given that psychodynamic work involves both you and your client coming to a deeper understanding of his/her internal world, the emergence of new information which enriches or alters your formulation is to be expected if the work is going well. If the intervention is structured you may need to explain a change of direction in the work, or a decision to continue with the work as planned in the face of the new information, depending on the nature of the information. If the work is unstructured you might wish to reflect on the significance of the emergence of the new material at a given point in the therapy and the effect it has on the work.

Outcome and Follow-Up:

It is likely that your account of dynamic (rather than symptomatic) change will be descriptive. You need to address both the original treatment aims/action plan and any new aims that occurred during the course of treatment. You also need to address the client’s view of the work you have done together.

Reformulation:

Although there is no need to repeat what you have already included in the Intervention, this is your opportunity to discuss any deeper understanding of the client based on the intervention and (if you have finished therapy) the completion of the work.

Critical Evaluation - Professional and Ethical Issues:

The issue of consent is a particularly difficult one in psychodynamic work (see Howard, 2006). It is very difficult for the client to give properly informed consent until s/he has had some experience of psychodynamic work and how it affects her/him, by which time s/he is engaged in a process that may already have had powerful repercussions. This may be an issue you need to address in your case report.

References:

Coren, A (2001) Short-term Psychotherapy: A Psychodynamic Approach. Basingstoke: Palgrave Howard, S. (2006) Psychodynamic Counselling in a Nutshell. London: Sage

Lemma, A. (2003) An Introduction to Psychoanalytic Psychotherapy. London: Wiley Molnos, A (1995) A Question of Time. London: Karnac

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