When is a psychotherapy case beyond your scope of practice?
As a psychotherapist, I feel strongly that I am able to work with all clients who are not ‘psychotic’. The term ‘neurosis’, although withdrawn from DSM 5 (American Psychiatric Association, 2013), is probably the appropriate term to use here. I work with individuals suffering from any functional mental disorder who are not experiencing delusions or hallucinations. However, it is important to note that many people who have been given the label ‘psychotic’ have not been understood and have simply been labelled by a psychiatrist who has not had the time or energy to find out about the root cause of their anxiety. On many occasions, I have been referred a client who has been given the label ‘schizophrenic’ but has responded appropriately to a series of traumatic incidents in the family setting, and, by understanding these mechanisms, I have been able to help them with their psychological disturbance. In these cases, the diagnoses of schizophrenia have been incredibly unhelpful.
Nevertheless, generally speaking, I tend to work in the following areas (and this is certainly not a complete list):
Anxiety and Stress
Agoraphobia and Social Phobia
Preparation for MRI, CT Scan, Surgery, Invasive Medical Procedures, Dental Treatment
Gastrointestinal disorders such as IBS and Functional Bowel Disorders
Dermatological Disorders (e.g. such as Eczema, Psoriasis, Warts, Herpes Simplex)
Stuttering (including Nail biting, Smoking)
Cardiovascular Disorders (e.g. High Blood Pressure)
Nocturnal Enuresis (Bed Wetting)
Chronic Illnesses such as Cancer and Diabetes
Gynaecological Disorders (e.g. PMT, Dysmenorrhoea (Painful periods), Psychogenic Infertility
Psychosexual Dysfunction (e.g. Impotence, Premature Ejaculation, Frigidity, Vaginismus and Dyspareunia (Painful intercourse)
I do not treat individuals suffering from anorexia nervosa, alcoholics or drug abusers. I also tend not to work in acute mental health, although I have begun to work in this area in the hospital setting. It is my opinion that more psychodynamic psychotherapists should working in acute mental health, and in hospitals generally.
In some instances, I would not work with individuals, even from the list above. If you don’t feel comfortable or able to help in a situation, it is best to refer to another therapist. For example, agoraphobia is an extremely complex disorder to treat (Chambless, 1982; Kaplan & Sadock, 1991) and requires a great deal of expertise. I have successfully treated many individuals suffering from severe agoraphobia using a combination of psychotherapy and hypnotherapy; however, often there is so much resistance that one has to refer them on, either to their GP (if consent has been given), to a psychiatrist or to another psychotherapist. In some cases, individuals can be sent to centres that deal specifically with types of mental illness and a referral here might be suitable. However, these places are very expensive. I think that anorexia nervosa is probably the most difficult disorder to treat and often individuals simply show how self-sacrificing they are simply by refusing to come for treatment. I have worked with girls suffering from anorexia using psychotherapy and, occasionally, hypnotherapy. But, whenever progress is made, they stop the treatment. I think that I could only work successfully with someone suffering from anorexia if (s)he is in a hospital setting, and it is extremely difficult nowadays for psychotherapists to get placements in the NHS. Generally, these girls don’t turn up for their appointments; or, alternatively, they come on time but refuse to speak or work with me during the session.
Increasingly, there are more boys—particularly teenagers as young adults—that are presenting with anorexia. In 2007, an epidemiological study was carried out to investigate the incidence of AN in both men and women. This research, a population based study from the National Comorbidity Replication carried out by Harvard Medical School (N = 9,282), showed an incidence of anorexia nervosa of 0.9% in women and 0.3% in men. This study was based on a house-to-house survey on a national level using the WHO Composite Diagnostic Interview (Hudson, Hirip, Pope, & Kessler, 2007). These figures indicate that there has been an increase in the number of men with anorexia nervosa; this may be due to a definite increase in the number of men suffering from this condition or, alternatively, that diagnostic tools have improved to such an extent that researchers have been able to locate more men suffering from this condition (ANRED, 2008).
As a psychodynamic psychotherapist, it is important to work within the bounds of your own expertise.
David Kraft PhD
UKCP Registered Psychotherapist
Accredited by BSCAH
Fellow of The Royal Society of Medicine
Member of Council for Section of Hypnosis & Psychosomatic Medicine
Member of Council for BSCAH