HD 3700 1st Edition Lecture 26 Outline of Last Lecture I How to study for the final II Treating SCZ III Clinical Formulation IV CBT formulation with SCZ V Psychodynamic formulation with inpatient BPD VI Ophelia s psychotic grief Outline of Current Lecture I Case Study Leroy II Psychotherapy Outcome Research the Consumer Reports Study III Hamlet comes to a close IV The sense of an ending yours mine ours Current Lecture I Case Study Leroy Leroy o o o o o o o o o Considered mildly autistic on Autistic spectrum Would have meltdowns in class Needed rigid structure and expectations His passive indifference to mother s love Language delayed and eccentric Arms flapped body spun Avoided eye contact Leroy perplexed everyone and everyone perplexed him Two separate consciousnesses sit with Leroy even though Leroy cannot communicate talked about how he felt the morning before they were to meet o Child needed someone to connect with him o As a therapist he needed to make the connection that others couldn t he identified with Leroy s autism with being out of contact o Leroy runs to corner of room upon meeting therapist Leroy covers his ears o This is the moment where the therapist breaks in makes sniffing sounds with the puppet Leroy won t speak to therapist but would talk to puppet o You smell stuff I smell to explore the world o I smell things happen to me Leroy o Write letters to each other written observations confirm his view of reality o We see the same world o Climax of the therapy Leroy said Japan blew up Japan had never come up before Tell me about Japan blowing up Japan blew up o Japan was sad Does it have anything to do with Japan blowing up o Made in Japan sticker o When our time runs up do you feel blown up and sad Like I m broken o Letting him be as remote as he needed to be felt safe with therapist Forming the Alliance o Allowing for many sessions where Leroy played by himself o Respecting and honoring Leroy s need for silence Creating an interpersonal space o Responding to Leroy carefully allowing the boy to hear himself o Trying to find a way to communicate puppet letters Interpreting what the patient does doesn t know o Japan blows up o Trying to understand the meaning of what was being communicated o Leroy was telling him how much he liked therapy II Psychotherapy Outcome Research The Consumer Reports Study It is very difficult to measure the effect of psychotherapy Patient Therapist Variables how do you hold them constant Patient o Presenting symptoms o Capacity for therapy some people are resistant some take to it right away o Intelligence o SES and cultural background some cultures are more open to psychotherapy than others Therapist o Training therapy orientation o Experience o Effectiveness o SES and cultural background Process and outcome variables how do you measure them o 1 How do you measure the patient s functioning at baseline interviews self reports projective tests o 2 How do you measure the patient therapist relationship o 3 How do you set the length of therapy for measurement o 4 How do you measure the patient s improvement after therapy And so we get to the gold standard o Empirically based psychotherapy Single symptom Session by session treatment manual Treatment length is determined in advance Baseline and outcome measurements are standardized Seligman s Consumer Reports Study o Was a major proponent of empiricism o But was against empirically based psychotherapy o Survey of patients describing retroactively their experience with psychotherapy o Improvement higher the longer you were in therapy better with psychologist than family doctor Improvement for presenting symptoms Improvement over work and social domains Improvement over personal domains III Hamlet This is his death sentence and Hamlet knows Opens the letter and changes it so that the crown will murder Rosencrantz and Guildenstern his second and third murders From now on my thoughts will be bloody Hamlet says he still will kill Claudius He does not know that Ophelia has gone mad and drowned Hamlet does not know Laertes is angry although he killed his father and drove his sister mad Hamlet sees the grave of Ophelia challenges Laertes to a duel Hamlet is saying he has a bad feeling about this but forget it it s fine Horatio says no I will cancel the duel Hamlet says not a chance this life is temporary when we become ready we then die and go to heaven hell if we go to heaven that s the real life God is in control the only thing that s important is being ready to die we cannot own our reality know what s really going on in our life what difference does it make if I die early o But in this scene it does matter This is what the end of the play is going to challenge the reality of our psychological relationships of our experience has meaning Laertes stabs Hamlet Hamlet picks up his sword and wounds him with it Gertrude drinks from the poisoned cup and dies Hamlet kills Claudius Laertes forgives Hamlet and he dies Hamlet is saying I can t live long enough to explain what is happened to the country I need you to explain it Horatio Hamlet drinks from the cup and dies It does matter when he dies Hamlet s story will not be told if he dies In beginning he tells Horatio to drink we will go out and drink In end he tells him not to drink he will die and Hamlet s story will not be told IV The end The Two Red Chairs Therapist helped her to understand that every therapy session could be used to help her understand relationships how she made meaning how she felt afraid of her own emotions Let me mention one final lesson o Powerful emotions and destructive emotions are not the same thing o Difference between simple sadness and depressed sadness o Simple sadness felt for therapist when she left o It wasn t good and it wasn t bad it just was and it was so much