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Things to remind myself when having therapy with clients in the psychotic range: Nancy McWilliams

Sometimes I would be uncertain about my goals when working with clients in the psychotic range. However, Nancy McWilliams' book, Understanding Personality Structure in the Clinical Process: Psychoanalytic Diagnosis (2nd edition) reminds me what I should do, and enhance my reflection:

1. Clients in the psychotic-level psychologies are mostly terrified as they are lacking of a basic sense of security in the world and is ready to "believe that annihilation is imminent."

2. "Supportive therapy" could be important to them as it emphasizes on active support of the client's dignity, self-esteem, ego-strength, and need for information and guidance.

3. Remember there is a "continuum from supportive through expressive therapy" at the uncovering insight and resolution.


Points to note during therapy (from the start):

1. Demonstration of trustworthiness by real respect

2. Unwavering honesty and self-disclosure might be needed, in order to clarify their paranoid thoughts or unreal perceptions

3. Clarify client's fantasies

4. Be an ordinary human being, so you (therapist) can be at ease

5. Extend yourself to help in a more specific, problem-solving way than would be warranted in psychotherapy with healthier persons

6. Relate in a more authoritative way than with high-functioning clients: by behaving like a professional expert but a human equal; engaging in egalitarian tone which is nonhumilating; while the sense of authority reassures them that the therapist is strong enough to withstand their fantasized destructiveness

7. Provide explicit psychoeducation about what feelings are

8. Normalization is important


Extracted from : Chapter 4: Implications of Developmental Levels of Organization


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