Clients With Serious Mental Health Issues

Psychoanalytic theory maintains that psychological disorders are the result of unconscious conflicts becoming extreme or unbalanced. Freud suggested that severe mental health issues consist of a constellation of symptoms that are caused by intrusions of hidden drives into voluntary behavior when defense mechanisms fail, and the psychoanalytic approach assumes that all presented symptoms are meaningful and relevant to the client's subjective experience and are therefore useful in treatment. For example, hallucinations are understood and interpreted like dreams, and delusions are understood primarily as transference to the world at large. In the case of Axis II disorders, primarily borderline personality disorder, attachment issues early in life are the main focus of treatment, and self-destructive behaviors and acting out are framed as defenses against feelings of abandonment (Camitz, 2006).

The unconscious is the primary focus of treatment, and when used in the treatment of serious mental illness, the aim is to trace the overt symptoms of the diagnosis back to their unconscious origins and analyze them through the use of rational thought and processing. The goal is to develop a sense of stability in the client through emotional processing of the past and linking to the present, and to synthesize the personality components into one functional unit.

For many clients with serious mental health issues, client symptoms and concerns need to be addressed early and proactively, and counselors need to be acutely aware of their own feelings during these interactions. However, Seligman and Reichenberg (2007) noted that countertransference may be useful in understanding these clients, as reactions may enhance understanding of reinforcing social interactions beyond the session. Examining the countertransference reactions using psychoanalytic techniques should be done in a supportive, empathetic manner, and Seligman and Reichenberg further cautioned counselors to seek supervision to maintain their objectivity.

The degree to which structure and support is provided by the counselor depends on the functional level of the client. Conscious insight is helpful but is only effective in a strong, stable, and safe therapeutic relationship. The counselor is responsible for modeling a healthy ego, and the relationship with the counselor is internalized as what a human relationship might be like. The client is encouraged to keep the internalizations that are useful, and as the client gets healthier, he or she takes a more active role than the counselor in the therapeutic relationship.

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