Therapy Journal
Effective psychotherapy requires that the therapist keep notes of the major themes and important events that occur in the sessions. The therapist should regularly review these notes in order to maintain an integrated view of the patient from session to session and for the work in the sessions to build on past sessions. Although therapy notes will contain considerable factual material, the most valuable information is usually that of here-and-now interactions with the therapist that helps elucidate common patterns of behavior and interpersonal relationships that is a common thread that runs through the patient's life.
The therapist looks in particular at information from 3 corners of a triangle: 1.) relationships from the past, 2.) relationships in the present outside of the therapy, and 3.) the relationship with the therapist. The therapeutic relationship must be prepared for this level of inquisivity as it is not usual to look so intimately at the details of interpersonal interaction in the usual social setting. Looking at the content of dreams is another way to investigate the major themes that both motivate people and give them conflict, and I recommend to keep a dream log near one's bed to present in the sessions.
Developing a comprehensive view of the person's main drivers and areas of sensitivity (core issues), their life strategies and defenses that protect these sensitive areas, and how these strategies and defenses facilitate or hamper the person's relationships with others and overall psychosocial functioning is the common work for the therapist and patient. The patient is often not aware of the distinction of all these layers of their own complexity and they require guidance in this regards from the therapist.
This page is aimed at providing a candid look at what happens in therapy sessions from the therapist's position. I would recommend you read the other pages in the Approach section to have a full understanding of the therapeutic process before reading the Therapy Journal. The names, demographics, and most of the therapy details in the Therapy Journal have been modified so that the examples are largely fictional.
Doug Berger, M.D., Ph.D.
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JOURNAL ENTRIES
(The names and details in this section are fictional)
Susan
Susan is an American in her 40’s with a presenting complaint of depression. As a defense against fear of rejection (a core issue), she has been somewhat submissive to her husband because she fears he would leave her if she was too assertive. She is resentful underneath at having to be submissive and is passive in a way that seems passive-aggressive which actually aggravates him leading to distance between them as an active trouble, and to her becoming depressed as a secondary trouble. In the sessions, she seems to passively want me to fix her. She is becoming aware of this pattern slowly.
Steven
Steven is a British lawyer in his 30s with depression and trouble connecting to people. Though he has girlfriends he always ends up breaking up with them and tends to pornography. He had been in therapy with me for a short while a few years ago but stopped after a few months, and was thinking of stopping again a few months ago, in spite if his desire to fix his issues and his very positive feelings to me.
He seems quite personable but tends to argue points in subtle indirect ways. He wants special treatment regarding the cancellation policy and emphasizes the important postion he is in at work. He often will not return phone calls and is vague about the reasons. He reports dreams of people fighting. His mom was very strict and put him down constantly.
He has been difficult to figure out because he has a complex multiple core issue-defensive structure. He seems to have a wall around him in general with his intimates and with me, and he has tried to reject me a few times (by quitting the therapy) as a defense against feeling he will be rejected first. I think he uses the “important position” he is in work statement as a smoke-screen defense against the more embarrassing actual defense of “I want to feel I am liked by you and to this end I want you to show me I am not just any patient to you by giving me special treatment on the cancellation policy”.
He has also argued points about psychiatric theory and the cancellation policy with me in a way that feels like a competitive struggle, which indicates that control is another core issue. Struggles for control as exhibited by these debates and his dreams also conveniently serve to keep his focus off the more emotionally cutting issue of his fear of rejection. This fear of rejection also is the cause of the wall he keeps around himself (his focus on pornography instead of real women is just an example of being surrounded by the wall). He also has passive-aggression exhibited by not returning phone calls and withholding love from his girlfriends. His career as a laywer may represent a way for him to debate in a socially acceptable fashion.
I will need to get further through his logic-chopping before he can really see the whole picture. It may be effective to appeal to his intellectual self to become interested in the issues of psychologic mechanisms, and I'll have him re-read the Approach section of the home page carefully.
Thomas
Thomas is an American English teacher in his 40s who came to me because he has had ongoing conflict with his wife since he had told her a few months ago that he was having an affair with another woman. About a year ago he had a bout with cancer, and with surgery and treatment he survived. The illness made him feel that there was little time left in life and he felt this may be his last chance to fulfill strong sexual needs that his relationship with wife did not. He still very much loved his wife who was 10 years his senior and he did not want to divorce. He always longed for sex with other women, but up until the cancer he had suppressed these needs, having a sexual life in fantasy, and feeling guilty towards his wife whenever he thought about actually crossing the line.
What had happened was that the cancer tilted a precarious balance of psychologic defenses in him. He had always seen his wife as a mother figure and was more interested in her in a family sense than as a romantic partner. Before the Cancer he had used supression and fantasy defenses against his sexual needs because of a low threshold to feel guilt and fear of punishment. The near-death episode with cancer allowed him to temporarily jump over this low guilt threshold and he started an affair, but when the dust settled on the initial excitment with the new woman he was left with a massive load of guilt he felt he had to let off by telling his wife about this other woman. His wife reacted very strongly to this confession and is now berating him badly almost daily. He has thus received the punishment he unconsciously felt he deserved for his transgression; although with the stress of all the conflict with his wife leading him to seek help with me.
So essentially he was always stuck between lack of sexual satisfaction on the one side vs intense guilt and need to receive punishment (defense against the guilt) on the other side. The backdrop was his childhood relationship with his mother who he had trouble separating from, and to whom he felt he always had to please (core issues of separation/individuation); relived now as an adult in the marriage with his wife. Before the cancer he only had the trouble of lack of sexual satisfaction; now, in addition to this, he also has the active trouble of conflict with his wife.
This man's psychological complexity challenged my ability to understand him. It was necessary both to break down the story into its component pieces by comparing the types of defenses used before and after a "watershed event", (i.e. this man's bout with cancer); and to see the big picture in the style of his intimate relationships over the course of his entire life (ie. the similarities in the relationship with his mother and wife). These views helped bring an understanding of this man's psychological and emotional life into clearer focus.
The treatment will help him see the interplay of his different defenses and how they provided him an unsatisfactory and tenuous psychological balance. As a concrete support, if he can begin to see the needs of his wife instead of only his own needs he might be able to bring down her fury slightly (i.e., convince her how attracted he really is to her and assure her he will never leave her). Eventually he will need to come to another equilibrium or balance between his defenses, and since he has no desire to break up with his wife, he will need to find more satisfaction in his love for her rather than his previous focus on his missing sex life.
セラピージャーナル
有効なセラピーを行うため、セラピストは診療の重要な内容を記録しなければなりません。 継続的なセラピーに当たって、クライアントが抱えている問題を十分把握し、また、前回の重要なテーマを次の面接へ持っていくためにこの記録を復習や予習すべきであると考えます。記録には、本人の具体的な情報、さらに重要な本人の人間関係のパターンを把握するために、セラピストへの接し方を見極めた２つのデータが必要です。
特に、次の三点は重要です：1.) 過去にあった関係, 2.) セラピー以外の現在にある関係、 3.) セラピストとの関係。また、詳しく顧みない普段の人間関係は、 セラピストへの接し方を詳しく分析することが大事であり、そのためには事前に十分に説明が必要です。また、無意識にある葛藤や希望の内容を探求するのに夢分析も用い、布団の隣に夢日記をおいて、起床時に記録をとるのも大事だと思います。
本人の中核問題（敏感なところや動機を形成する）を守るため本人が使っている精神防衛、 またこの精神防衛が人間関係や精神社会的機能に対してどのように影響を及ぼすのかがセラピーの主とした作業です。普通は、クライアントは自分の心理や行動にこれほどの複雑さがあることを知らず、セラピストからの導きが必要と思われます。
セラピストの立場からセラピーに対するもののみかたを提供するのがこのページの目的です。セラピープロセスを十分把握ため「セラピージャーナル」を読む前に「アプローチ」欄にある情報を先に読むようにお勧め致します。また、このジャーナルの内容及び症例の名前はフィクションです。
バーガー ダグラス 精神科医・医学博士
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ジャーナル記録：
（このジャーナルの内容及び症例の名前はフィクションです）
鈴木さん
鈴木さんは40代後半の独身女性です。大手企業の会社員をしています。彼女は恋愛関係に行詰まりを感じて相談にきました。最近付き合っている男性は、道端で声をかけられた魅力的な男性ですが、実は既婚者です。彼女は彼と長く不倫関係を続けて、最近疲れ果ててきました。その前の彼とは11年の付き合いで、結局振られてしまいました。
仕事は上司が嫌いで転職を希望しているのですが、中々実行に移せないままです。それでも最近やっと上司に「もう少し配慮していただかないと、会社を辞めます」と言ったのですが、彼女には自信が欠如しているので、キャリア・アップの為に転職活動を始めるまでには至っていません。
彼女の中核問題としては、次のことが挙げられます。まず、彼女自身に「愛されていない」という感情が潜んでいることです。この感情に対して、依存行動という精神防衛策を用いながら、以前の１１年の関係や最近の不倫関係を長引かせてしまったのかと考えられます。その結果、問題点としては、精神的疲労、幻滅感や絶望感に至ってしまっているのです。次に、こういう状態にいる故、拒絶感から逃避したい為に、中々独身市場に出ることが出来なくなっています。その結果、自分が色々と男性を選べる立場ではなく、彼女に接近してくる男性に簡単にのめり込んでしまって、結果的に効率的な人生を歩めなくなってしまっています。
カウンセリングの過程で、彼女にこのパターンを認知させ、彼女の自信を高め、自己の精神安定をいかに守るかを改めて考えさせることで、非適応的な精神防衛策によるトラブルを軽減出来る様に、セラピーを行う方針です。
平田さん
平田さんは20代の独身女性で、保母さんです。幼少時、教育や躾の厳しい家庭で育ち、 高校の反抗期時代に風俗のアルバイトをしていました。当時、お客さんと暴力的な喧嘩をして怪我を負ったこともあったにもかかわらず、結局この仕事を２－３年間も続けてしまいました。その結果、現在は精神的な落ち込みと男性不審感に苛まれ、多くの面で公私共に上手くいかず、カウンセリングを受けに来ました。
彼女は、最近付き合っていた彼とは、性的な興味が薄れてしまい、自分から別れを切り出したところです。新しい彼が出来ても、過去の苦い経験から男性に不信感を強く抱いてしまい、親しくなれないという状態です。それに加えて不眠症や食欲・気力・集中力の減退もあり、時々自殺願望に悩まされているようです。
彼女の中核問題としては、「男性にコントロールされたくない」や「男性に認められない」という感情を挙げることが出来ます。本来は彼女が男性をコントロールしていても、段々自分の周りに防御の壁を築いてしまい、好きな人とはなかなか打ち解けず、結局先に振られてしまいます。男性に認められたいのに、男性からコントロールされるという恐怖感も強いので、男女関係が上手くいかず二次的にうつ状態になってしまうのです。
治療としては、まず彼女に非適応的な精神防衛策を気付かせ、「防衛の壁」を作らずして「コントロール」を完全にしなくても良いように、自己の精神防衛策を変えるように勧めます。また、セラピーによって、彼女に信頼感や称賛を与えることで、少しずつこの壁を取り除いて、セラピストをコントロールしないような（する必要が無い）関係を築く必要があります。しかしながら、このような治療をしても尚も二次的な坑うつ症状が改善しない場合は、坑うつ剤を投与する必要もあると考えられます。