Having just terminated with my only individual client this year, I am reflecting back on our time together. One of the key parts of the DBT framework that we operated under was the idea of therapy-interfering behaviors. In addition to focusing on the client's behavior, DBT requires the counselor to look at their own behavior and see how it interferes with the therapeutic work. Within the setting of the hospital, I found that the structure of the setting also interfered with treatment. Her primary therapist would schedule appointments during her skills group, because she was on the civil side of the hospital and did not know the treatment schedule (or ignored it). My client would often be off of the ward during we had scheduled to meet because the ward had gone outside to enjoy the nice weather. Also, my schedule did not always allow for us to meet, especially on days where I was sick or had to leave work early. On these days, I violated Linehan's mandatory notification for cancelling appointments.
In reflecting back, I also feel a certain sense of loss I hadn't really felt before in working with other clients over the termination of the therapeutic relationship. Perhaps it was that I was more emotionally invested in this relationship because my role was to positively reinforce all of her efforts and to provide an enthusiastically supportive environment for her. I would psych myself up before each meeting, so that even though we were generally going over pretty boring material (interpersonal effectiveness is not the most interesting DBT module), I would present and engaging front for my client to work with. Perhaps it was that this case was the one on which I worked most closely with the administrators and other treatment staff. I was tasked with creating a behavior plan and received supervision from the clinical administrator. Perhaps it was that this was part of a unit-wide program of implementing DBT for the traumatized women on the ward. I guess it was a combination of those factors that left me with more sadness at the end of the therapeutic relationship.
Friday, April 30, 2010
Tuesday, April 20, 2010
Competency
Having led a legal competency group since my first week at St. Elizabeth's, I'm only now getting a clear picture of some of the intricacies involved in "competency." These issues came up today in placement in a number of different circumstances.
H. is a client who is highly intelligent (a former college professor) who has been diagnosed with schizophrenia. Her prominent symptoms include persecutory delusions, which cloud her judgment. Her case highlights the two different kinds of competency. Her legal competency evaluation hinged on her rationality, as her factual understanding was intact. She rightfully pointed out the subjectivity involved in an assessment of rationality. Indeed, her medical competency was evaluated by two different committees who arrived at two different conclusions. She learned that the second committee found that she was not medically competent to refuse medications. She reacted violently to this news and created a pretty intense situation on the ward.
The relevant point here is that a person can be legally incompetent to stand trial yet be medically competent to refuse medications. Oddly, a mentally ill person is usually assumed to be legally incompetent; whereas, they are assumed to be medically competent. Since legal competency usually implies psychiatric medication, H's legal competency was entangled to an even greater degree with her medical decisions.
The other patient L is an example of when competency cannot be restored. L's schizophrenia symptoms cause her thoughts to be disorganized and her cognition about her case to be impaired. Since she had been to court for hearings three times, she is going to be civilly committed if she does not pass this competency evaluation. Our hospital is now trying to give some empirical evidence of incompetency, so she will be the first patient I've had who will be completing a formal battery/assessment of competency (a written test). However, these tests are not able or less able (according to the administrators on my ward) to assess the rationality of a person. For many of the clients, the rational part of competency is the problem, as the thought disorder impairs a full-enough level of rational thought.
The happier part of today was learning that two of my clients had passed their competency assessments, and seeing the progress they had made over the past few months. Makes that whole self-efficacy piece for me that much more evident.
H. is a client who is highly intelligent (a former college professor) who has been diagnosed with schizophrenia. Her prominent symptoms include persecutory delusions, which cloud her judgment. Her case highlights the two different kinds of competency. Her legal competency evaluation hinged on her rationality, as her factual understanding was intact. She rightfully pointed out the subjectivity involved in an assessment of rationality. Indeed, her medical competency was evaluated by two different committees who arrived at two different conclusions. She learned that the second committee found that she was not medically competent to refuse medications. She reacted violently to this news and created a pretty intense situation on the ward.
The relevant point here is that a person can be legally incompetent to stand trial yet be medically competent to refuse medications. Oddly, a mentally ill person is usually assumed to be legally incompetent; whereas, they are assumed to be medically competent. Since legal competency usually implies psychiatric medication, H's legal competency was entangled to an even greater degree with her medical decisions.
The other patient L is an example of when competency cannot be restored. L's schizophrenia symptoms cause her thoughts to be disorganized and her cognition about her case to be impaired. Since she had been to court for hearings three times, she is going to be civilly committed if she does not pass this competency evaluation. Our hospital is now trying to give some empirical evidence of incompetency, so she will be the first patient I've had who will be completing a formal battery/assessment of competency (a written test). However, these tests are not able or less able (according to the administrators on my ward) to assess the rationality of a person. For many of the clients, the rational part of competency is the problem, as the thought disorder impairs a full-enough level of rational thought.
The happier part of today was learning that two of my clients had passed their competency assessments, and seeing the progress they had made over the past few months. Makes that whole self-efficacy piece for me that much more evident.
Wednesday, April 14, 2010
Medical Model and Traditional Treatment
One of the strange things about being a social worker in a medical setting is the difference between the professional cultures. Social workers have a different attitude and focus than psychologists, psychiatrist, physicians, and nurses. However, in observing and participating in groups with social workers who have worked in this setting for a long time, I have seen the creep of the medical model into social work practice and it's genuinely disturbing.
As an example, I attended a Discharge Planning group on the civil side of the hospital which was lead by a social worker. She spoke about CRF homes and how stepping down works. While I took issue with some of her interpersonal style, which lacked empathy and a skill-building approach, those seemed like more surface-level concerns. The clients, meanwhile, were venting their frustration over the lack of control over their discharge plan (as well as their life, in general) and the lack of autonomy they experience in the hospital. Instead of validating these concerns or showing them some skills on self-advocacy within the setting, she seemed focused solely on apologizing for the system and instilling in the patients the supreme need of medication compliance.
While I understand that medications do help those with severe mental disorders function better in the community, it is ultimately up to the client to make the decision to continue or discontinue medications. Although this is a radical viewpoint, if the client were to discontinue medications and make his reasons known to his care workers, it could be interpretted as a growing sign of independence from treatment staff and ownership of his mental health issues.
As an example, I attended a Discharge Planning group on the civil side of the hospital which was lead by a social worker. She spoke about CRF homes and how stepping down works. While I took issue with some of her interpersonal style, which lacked empathy and a skill-building approach, those seemed like more surface-level concerns. The clients, meanwhile, were venting their frustration over the lack of control over their discharge plan (as well as their life, in general) and the lack of autonomy they experience in the hospital. Instead of validating these concerns or showing them some skills on self-advocacy within the setting, she seemed focused solely on apologizing for the system and instilling in the patients the supreme need of medication compliance.
While I understand that medications do help those with severe mental disorders function better in the community, it is ultimately up to the client to make the decision to continue or discontinue medications. Although this is a radical viewpoint, if the client were to discontinue medications and make his reasons known to his care workers, it could be interpretted as a growing sign of independence from treatment staff and ownership of his mental health issues.
Wednesday, April 7, 2010
Substance Abuse
Most of the patients at St. Elizabeth's have a severe mental illness, homelessness, and substance abuse issues (most often crack or alcohol). Since I had done research on substance abuse for the majority of my time at GMU, I was interested in how substance abuse interacted with psychotic disorders. Specifically, I was interested in if the drugs reduced some symptoms of mental illness. If we were able to see what these drugs did for people, perhaps we could fill that void with something less damaging.
From the research I found, there is no clear picture. For some, cocaine can ameliorate some of the negative symptoms; however, it can also exacerbate the positive symptoms--especially at high doses. Unlike what I had been told in school, the only drug that was statistically shown to lead to greater instances of mental illness was marijuana, and that connection was fairly week. (This is excepting drug-induced psychosis).
Another research area I explored was the idea of using harm reduction with many of the patients. This concept, glossed over in the readings, is in dire need at the hospital. Our clients have often prostituted themselves to support their habit, use in unsafe locations, and are in abusive relationships (often with a pimp). However, there are no services on the ward for those who do not wish to give up this lifestyle immediately or completely. It is merely assumed that when a person is on the ward, their natural goal will be to completely abstain from all substances. (Fortunately, we do have a psychiatrist who emphasizes that if they do relapse, they should continue taking their medication and can still seek help at the hospital.) Formally, there is no education on safe sex practices or safer/reduced drug use.
I was in the process of deveoping a plan to implement a harm reduction group on our ward; however, I could not find materials on harm reduction and domestic abuse. Since our clients are often in exploitative, abusive relationships, this would have been key. Also, I feel that the gender dynamic may have been inhibiting in creating an open environment to share experiences. The hospital itself would have likely been the largest obstacle, in that harm reduction does not fit well into the medical model of treatment and can be construed as endorsing continued substance use or prostitution. It would have made a nice thesis topic, though.
From the research I found, there is no clear picture. For some, cocaine can ameliorate some of the negative symptoms; however, it can also exacerbate the positive symptoms--especially at high doses. Unlike what I had been told in school, the only drug that was statistically shown to lead to greater instances of mental illness was marijuana, and that connection was fairly week. (This is excepting drug-induced psychosis).
Another research area I explored was the idea of using harm reduction with many of the patients. This concept, glossed over in the readings, is in dire need at the hospital. Our clients have often prostituted themselves to support their habit, use in unsafe locations, and are in abusive relationships (often with a pimp). However, there are no services on the ward for those who do not wish to give up this lifestyle immediately or completely. It is merely assumed that when a person is on the ward, their natural goal will be to completely abstain from all substances. (Fortunately, we do have a psychiatrist who emphasizes that if they do relapse, they should continue taking their medication and can still seek help at the hospital.) Formally, there is no education on safe sex practices or safer/reduced drug use.
I was in the process of deveoping a plan to implement a harm reduction group on our ward; however, I could not find materials on harm reduction and domestic abuse. Since our clients are often in exploitative, abusive relationships, this would have been key. Also, I feel that the gender dynamic may have been inhibiting in creating an open environment to share experiences. The hospital itself would have likely been the largest obstacle, in that harm reduction does not fit well into the medical model of treatment and can be construed as endorsing continued substance use or prostitution. It would have made a nice thesis topic, though.
Tuesday, April 6, 2010
DBT and behavior planning
In preparation for working with my client with Borderline Personality Disorder, I had read the book excerpted for this week's reading. The first thing the ward administrator--who is heading up the effort to engage the client in DBT-- and I did was to draft a list of the client's most high-risk behaviors. In the process, we were struck by how much progress she has really made while on the ward and how much she has begun to engage treatment, DBT in particular.
I was tasked with drafting a behavior plan for the client. From my years working with emotionally disordered kids and writing/implementing behavior plans, it is one of the few things I feel fully competent in doing. However, the behavior plans I had drafted in the past were grounded in a cognitive-behavioral methodology. While DBT is grounded in CBT, it has unique aspects that were interesting to explore in the process of writing the plan. Another confound was the influence of Trauma-Informed Care, another methodology being implemented across the hospital. This process eschewed the behaviorist interventions of a daily inventory (diary cards in DBT), a token economy, and ABC processing. Instead, TIC promotes understanding of self-soothing methods and bodily awareness during stress.
Integrating these plans was difficult for me and the other members of the treatment team. We ended up throwing out most of the behavior plan I had drafted because it was too CBT-oriented and instead favored a more TIC-centerd approach to behavior processing. However, the overall DBT structure within the forensic setting (there is an entire chapter on it in the book you excerpted for class) remains intact.
I was tasked with drafting a behavior plan for the client. From my years working with emotionally disordered kids and writing/implementing behavior plans, it is one of the few things I feel fully competent in doing. However, the behavior plans I had drafted in the past were grounded in a cognitive-behavioral methodology. While DBT is grounded in CBT, it has unique aspects that were interesting to explore in the process of writing the plan. Another confound was the influence of Trauma-Informed Care, another methodology being implemented across the hospital. This process eschewed the behaviorist interventions of a daily inventory (diary cards in DBT), a token economy, and ABC processing. Instead, TIC promotes understanding of self-soothing methods and bodily awareness during stress.
Integrating these plans was difficult for me and the other members of the treatment team. We ended up throwing out most of the behavior plan I had drafted because it was too CBT-oriented and instead favored a more TIC-centerd approach to behavior processing. However, the overall DBT structure within the forensic setting (there is an entire chapter on it in the book you excerpted for class) remains intact.
Wednesday, March 3, 2010
Suicide (repost)
I was a little reticent to share this because it ends up going pretty far out there, and I hope this is a place where I can share my true reactions, be they wrong or right, somewhere in between, or just south of normal. Before sharing, I just want to reassure you that I know my ethical obligations under the law and would not come close to considering implementing what I advocate here. Please don't take this as anything more than idle speculation. These were my reactions from my last week's community practice class and the section on suicide in the readings:
Our community-centered practice course featured a woman whose husband had committed suicide. She made many philosophical errors in her subsequent advocacy but made a few courageous stands. Her first act of sheer bravery was to tell her children that their father had committed suicide after it had happened. Society would generally tell her to hide it from them and reveal it when they were older. However, given my experience with adoption and my parents telling me (not the same, but the reveal could be just as powerful or traumatic), that this was an amazing decision! My parents were counseled to do what they did. She made her decision on her own (or as she says, through god). And I'm willing to bet that if she had consulted a mental health professional, slaves to traditionalism as we are, we would uphold the social order and tell her to lie to her children until they were older and ready to handle it (the suicide, that is-- because they might not be ready to handle knowing you have lied to them during the intervening years).
The second act of courage is also where she starts running into philosophical problems. She became and advocate for survivors of suicide (the term for those grieving a completed suicide) as well as suicide prevention. She stands athwart school districts who would rather pretend that suicidal and parasuicidal behavior do not exist, and is working to introduce an educational curriculum into school districts in the suburban Virginia area. However, when I asked her about the sociological impact of introducing that campaign, she seemed only to grasp that her program might reduce suicide. She furthered that sentiment by implying that she would like to eradicate suicide. I asked her if by talking about suicide and putting it out into the open, she might be normalizing suicide, making it less taboo of a subject. This would certainly lessen the shame of survivors and the blaming of the survivors for the suicide (hello, just-world fallacy). I didn't want to push the subject because from the tone of her voice and body language, she was visibly upset. But it was scary to me that she wouldn't have thought of these implications, since she is trying to affect social change and that implies a shift in ideas. Just as harm reduction and rational drug education programs can help those who choose drugs to do so more safely, they also make it less taboo for drugs to be used or to have a member of the family who uses drugs. It's not the intended effect, but it nevertheless exists.
I have some other issues with things she said, but I don't want to ridicule the woman. She obviously found a very positive way to cope with a terrible scenario and did so in a way that questioned the proper behavior for a survivor.
Now, onto the meaty theoretical discussion on why suicide is neither good nor bad. My professor made the terrible mistake of trying to stake out a middle ground between all suicides are bad (or are fomented by mental illness) vs. suicide is neither good nor bad. She intimated that she held some sympathy for those who were chronically physically ill and made the rational choice to end their lives, rather than go through months of torture and pain. This was perhaps acceptable to her, but those who are "mentally ill" and make the same calculations must be saved from themselves. Why?
My original reaction was simply on principle (read below), but in revisiting the topic, I can also see flaws in the utilitarian arguments. First, people in chronic and severe pain, those who are suffering from a long-term degenerative and fatal disease, are going to think differently than those who do not have said ailments. Chronic pain is associated with major depression. Terminal illnesses create existential quandaries whose intricacies must be navigated by someone whose cognitive processes may be altered by physical conditions. So, the population of physically ill and mentally ill may have more overlap than is generally offered in their decision-making capacity. How can a clinician judge a person with a terminal illness to be rational to make a decision when a person with chronic depression would have his or her judgment questioned?
Second, the utilitarian argument that most readily comes to mind that would justify paternalistic intervention would be that a mentally ill patient may not be able to conceive of what the future will be like: once treated in a hospital, they will return to baseline; once they undergo this other type of therapy, they will no longer want to die; or their reasoning makes no sense at the present time. But, the same logic would then have to apply to those who are physically ill and may find a cure, different treatment, or are in an acute crisis. How do you respect one set of people and deny another?
But still, in spite of all of this similarity, the two just FEEL different. On a scale of provisional morality (0 being saintly, 1 being satanic), perhaps accepting a person's suicidal judgment would be a .4 for those who are physically ill (still bad, but not terrible) and .8 for those who are mentally ill. With that in mind, let's explore the "what if." What if you were to accept a client's goal of committing suicide? How would you guide him or her?
There are resources, however unused, on how to kill oneself including a manual called the Peaceful Pill Handbook (now a website) which ranks methods of suicide along a scale which includes the method's reliability, peacefulness, availability, preparation, undetectability, speed, safety, and storage. Apparently, there is also the Hemlock Society which advocates for the rights of those who wish to commit suicide and provides some community support. In practice with the client, grief textbooks can be reverse-engineered to create a way for the person to inform their families of their intentions, allow them to say goodbye, and understand the reasons they are ending their lives. In the invention of the suicide note, it seems as if it is important for the person committing suicide to convey their reasons and feelings. This may lessen the families ambiguity following the death, as well. Furthermore, by becoming educated on the methods of suicide, they may choose to end their lives in the least gruesome way, lessening the trauma on the family even further.
These methods and resources may (and I stress may) be congruent with harm reduction methods. They are certainly consistent with the person's autonomy, dignity, and free will. Social workers cannot ethically act in a paternalistic manner towards their clients, and respecting their wishes, no matter how incomprehensible, must remain paramount; however, we are called on to protect the lives of clients by force (if necessary) if they plan to commit suicide. How do you deal with those conflicting imperatives?
The harm-reduction line of thought came after my initial reaction to the debate, which was slightly more tendentious: My professor made a comment and the words are escaping me, but they belied the most heinous of value judgments. Who decides whether a person's life is worth living? A social worker or the person? If you have a patient who is severely depressed and has exhausted all of his or her treatment options, why is it wrong for them to conclude that suicide is preferable to life? You don't know their life. You can only glean from their statements how they feel on a daily basis. How can a clinician ethically judge another's life worthy objectively and unilaterally? Is it like a reader judging the principle inherent in the death of Socrates?
Do you view people as a means to an end or as ends in and of themselves? If it's the latter, I think these types of questions need to cross your mind.
Our community-centered practice course featured a woman whose husband had committed suicide. She made many philosophical errors in her subsequent advocacy but made a few courageous stands. Her first act of sheer bravery was to tell her children that their father had committed suicide after it had happened. Society would generally tell her to hide it from them and reveal it when they were older. However, given my experience with adoption and my parents telling me (not the same, but the reveal could be just as powerful or traumatic), that this was an amazing decision! My parents were counseled to do what they did. She made her decision on her own (or as she says, through god). And I'm willing to bet that if she had consulted a mental health professional, slaves to traditionalism as we are, we would uphold the social order and tell her to lie to her children until they were older and ready to handle it (the suicide, that is-- because they might not be ready to handle knowing you have lied to them during the intervening years).
The second act of courage is also where she starts running into philosophical problems. She became and advocate for survivors of suicide (the term for those grieving a completed suicide) as well as suicide prevention. She stands athwart school districts who would rather pretend that suicidal and parasuicidal behavior do not exist, and is working to introduce an educational curriculum into school districts in the suburban Virginia area. However, when I asked her about the sociological impact of introducing that campaign, she seemed only to grasp that her program might reduce suicide. She furthered that sentiment by implying that she would like to eradicate suicide. I asked her if by talking about suicide and putting it out into the open, she might be normalizing suicide, making it less taboo of a subject. This would certainly lessen the shame of survivors and the blaming of the survivors for the suicide (hello, just-world fallacy). I didn't want to push the subject because from the tone of her voice and body language, she was visibly upset. But it was scary to me that she wouldn't have thought of these implications, since she is trying to affect social change and that implies a shift in ideas. Just as harm reduction and rational drug education programs can help those who choose drugs to do so more safely, they also make it less taboo for drugs to be used or to have a member of the family who uses drugs. It's not the intended effect, but it nevertheless exists.
I have some other issues with things she said, but I don't want to ridicule the woman. She obviously found a very positive way to cope with a terrible scenario and did so in a way that questioned the proper behavior for a survivor.
Now, onto the meaty theoretical discussion on why suicide is neither good nor bad. My professor made the terrible mistake of trying to stake out a middle ground between all suicides are bad (or are fomented by mental illness) vs. suicide is neither good nor bad. She intimated that she held some sympathy for those who were chronically physically ill and made the rational choice to end their lives, rather than go through months of torture and pain. This was perhaps acceptable to her, but those who are "mentally ill" and make the same calculations must be saved from themselves. Why?
My original reaction was simply on principle (read below), but in revisiting the topic, I can also see flaws in the utilitarian arguments. First, people in chronic and severe pain, those who are suffering from a long-term degenerative and fatal disease, are going to think differently than those who do not have said ailments. Chronic pain is associated with major depression. Terminal illnesses create existential quandaries whose intricacies must be navigated by someone whose cognitive processes may be altered by physical conditions. So, the population of physically ill and mentally ill may have more overlap than is generally offered in their decision-making capacity. How can a clinician judge a person with a terminal illness to be rational to make a decision when a person with chronic depression would have his or her judgment questioned?
Second, the utilitarian argument that most readily comes to mind that would justify paternalistic intervention would be that a mentally ill patient may not be able to conceive of what the future will be like: once treated in a hospital, they will return to baseline; once they undergo this other type of therapy, they will no longer want to die; or their reasoning makes no sense at the present time. But, the same logic would then have to apply to those who are physically ill and may find a cure, different treatment, or are in an acute crisis. How do you respect one set of people and deny another?
But still, in spite of all of this similarity, the two just FEEL different. On a scale of provisional morality (0 being saintly, 1 being satanic), perhaps accepting a person's suicidal judgment would be a .4 for those who are physically ill (still bad, but not terrible) and .8 for those who are mentally ill. With that in mind, let's explore the "what if." What if you were to accept a client's goal of committing suicide? How would you guide him or her?
There are resources, however unused, on how to kill oneself including a manual called the Peaceful Pill Handbook (now a website) which ranks methods of suicide along a scale which includes the method's reliability, peacefulness, availability, preparation, undetectability, speed, safety, and storage. Apparently, there is also the Hemlock Society which advocates for the rights of those who wish to commit suicide and provides some community support. In practice with the client, grief textbooks can be reverse-engineered to create a way for the person to inform their families of their intentions, allow them to say goodbye, and understand the reasons they are ending their lives. In the invention of the suicide note, it seems as if it is important for the person committing suicide to convey their reasons and feelings. This may lessen the families ambiguity following the death, as well. Furthermore, by becoming educated on the methods of suicide, they may choose to end their lives in the least gruesome way, lessening the trauma on the family even further.
These methods and resources may (and I stress may) be congruent with harm reduction methods. They are certainly consistent with the person's autonomy, dignity, and free will. Social workers cannot ethically act in a paternalistic manner towards their clients, and respecting their wishes, no matter how incomprehensible, must remain paramount; however, we are called on to protect the lives of clients by force (if necessary) if they plan to commit suicide. How do you deal with those conflicting imperatives?
The harm-reduction line of thought came after my initial reaction to the debate, which was slightly more tendentious: My professor made a comment and the words are escaping me, but they belied the most heinous of value judgments. Who decides whether a person's life is worth living? A social worker or the person? If you have a patient who is severely depressed and has exhausted all of his or her treatment options, why is it wrong for them to conclude that suicide is preferable to life? You don't know their life. You can only glean from their statements how they feel on a daily basis. How can a clinician ethically judge another's life worthy objectively and unilaterally? Is it like a reader judging the principle inherent in the death of Socrates?
Do you view people as a means to an end or as ends in and of themselves? If it's the latter, I think these types of questions need to cross your mind.
Monday, February 15, 2010
I'm going to focus on the first client seen by the clinician in the video. In this example, the primary defense mechanism employed by the client is rationalization. During her explanation of her referral, she identified the perceived cause as her mother's lack of involvement in her life. While I can sympathize with feelings of empowerment and autonomy this disengagement brings, she evinces some ambivalence about her relationship with her mother. She externalizes her anxiety over her lack of a relationship with her mother on her teacher and administrators who referred her to the clinician. In addition, she minimizes and denies her lack of effort in the class by positing that it puts undue and unwarranted strain upon her ("I have to sleep") and that those around her are overreacting to her lack of effort in the class.
Perhaps those who referred her to the clinician perceive her lack of effort as a form of acting out in which she garners attention from her mother by failing a class. She lends credence to this theory in her reasoning of why she does not attend school. Her reason for not attending is that her mother does not take an involvement in her life and demand that she remain engaged in school. It seems also that she is seeking this understanding and involvement from her boyfriend, whom she describes as "the only one who understands me." I would take this a step further to say that he is the only one who takes the time or makes the effort to understand her.
Her negative emotions regarding her mother find further expression through her statement that "if she doesn't want to be there, I don't want her there." This is an example of "sour grapes" rationalization wherein she does not get what she desires (maternal guidance and interest) and then decides she never wanted it in the first place.
Further emotional content is gleaned from her projection of anger onto the therapist. She perceives the therapist's questions as judging her relationship (a natural defensive reaction to someone exploring a new topic in coerced therapy). The client then erects an emotional boundary, chiding the therapist as a power figure who will judge her life and see if more therapy is warranted. This is designed to show the therapist that her insights matter only on paper, not within her psyche. She confirms her denial and dissociation from her issues by saying that she does not want to think about this kind of stuff.
She does divulge some of her negative emotions towards her mother in her story about cooking. The lack of sympathy from her mother as well as the lack of instruction are demonstrated in her retelling her mother's response to her burning her hand during cooking. Again the ambivalence towards her mother's disengagement is evidenced by her implicit saying that she would not like to have been judged for cooking for herself (an independent, laudable act) and that her mother should just stay out of her business and let her be happy.
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