Psychotherapy approaches and clinical applications

CCRT attempts to discern what are the core, motivating 'wants' behind a patient's behavior. By exposing the hidden reasons for his or her negative behaviors, the client can become more mindful and hopefully change them. CCRT defines the 'wish' (W); the response from others (RO) and the response from the self (RS). In the case of Ms. A, her 'wish' seems to be for self-validation. Ms. A is a very insecure client, based upon her past experience of being sexually abused. Although she says that she wants to have an intimate relationship, her actual behavior in the therapeutic setting suggested that she had great fears of intimacy. Her unexpressed and subconscious 'want' may actually be 'not to be hurt,' rather than to have a relationship. As a result, when she has sexual intimacy with a man, taking the relationship to the next level (RO), her response from the self (RS) is to end the relationship. Often this takes the form of being increasingly demanding, growing frustrated with the man's behavior, and thus sabotaging the relationship and causing her to end it.

Using CCRT is particularly effective in dealing with a patient such as Ms. A, whose symptoms do not neatly fall within a specific disorder. Rather than attempting to classify her mix of neediness and avoidance as a personality disorder, given that otherwise the patient is extremely high-functioning, the use of CCRT allows the therapist to break down her behaviors and help her find ways of adopting more proactive strategies. It enables her to identify her avoidance behaviors and realistically evaluate the behavior of men in her life (Kassaw & Gabbard 2002:723). CCRT can also potentially alleviate some of the problems of patient transference -- patients often project emotions onto the therapists and while this is often a necessary transitional step it can also complicate the therapeutic relationship. CCRT provides a structured and less emotionally volatile way of evaluating patients' needs and wants.

Q2. Sexual abuse

According to Kassaw & Gabbard, Ms. A's recollection of sexual abuse is a so-called 'model scene' or a scene which the patient has identified as extremely formative in shaping her development. To some extent, her interpretation should be viewed with caution, given the vividness of her recollection. Additionally, Ms. A continues to have difficulties with her mother, whom she describes as alternatively controlling (discouraging her from seeking independence and moving away from home) and conservative (encouraging Ms. A to get married). However, the fact that the patient regards the scene as significant is itself noteworthy. Quite often the 'stories' patients tell about the origins of their problems are very useful and significant for the therapist, even if the therapist may not necessarily agree with the patient's interpretation. Ms. A views her sexual abuse at the hands of her uncle and her parent's under-reaction to the abuse as a critical component of her problems with men. This seems like a reasonable point-of-view, although a therapist should never take any statement by a patient at 'face value,' in the psychodynamic perspective. For example, Kassaw and Gabbard speculate that Ms. A may feel 'survivor guilt' about pulling away from her abuser and leaving her sister vulnerable. This might possibly explain why Ms. A has such a strong need to please others and hide her true feelings (Kassaw & Gabbard 2002:722).