MIRRORING AND THE THERAPEUTIC PROCES

Ovaj rad refleksija je na tekst pod naslovom „Psychosis Neurosis“. Ovaj tekst je svom terapeutu, u vidu e-pošte napisao, za mene anoniman pacijent. Čitajući spomenuti tekst asocijacije su me vodile u smjeru patologije selfa, odnosno zastoja u razvoju zbog nezadovoljenih self-objekt potreba. Budući da, osim pacijentova teksta, nije bilo dostupnih drugih podataka o pacijentu, sa sigurnošću se ne može tvrditi, već samo pretpostavljati o pacijentu, njegovoj dijagnozi, uzrocima njegova stanja ili tijeka i ishoda terapije. Budući da me pacijentov tekst asocijativno vodio u područje self-psihologije, u ovom radu posvetila sam se zrcaljenju, pitanju narcizma i narcističnih poremećaja ličnosti, pitanju selfa, self-objekt potreba te terapijskim mogućnostima narcističnih poremećaja s posebnim osvrtom na inačice transfera i važnost empatije. Spomenuti su i psihijatrijski poremećaji koji često dolaze u komorbiditetu s narcističnim poremećajima.This paper is a commentary on the Psychosis Neurosis story written by a patient to his therapist in an email form. The clues in the text have led me towards the pathology of the self, i.e towards the developmental arrest due to the unsatisfied self-object needs. Since no additional information was available about the patient, save for the email, we can only speculate about the patient’s diagnosis, the causes of his state, and the course and outcome of his therapy sessions. Due to the fact of me being led, associatively, towards self-psychology, in this work I focused on mirroring, narcissism and narcissistic personality disorders, the self, self-object needs, and therapeutic options for narcissistic personality disorders with special attention paid to the versions of transfer and the importance of empathy. I also mentioned some psychiatric disorders that often appear in comorbidity with narcissistic disorders

Perceived Self-Stigmatization of Patients Hospitalized at Psychiatry Department of Clinical Hospital Centre Rijeka

Cilj rada bio je ispitati samostigmatizirajuće stavove ispitanika iz skupine oboljelih od duševnih bolesti i utvrditi njihov stupanj samopoštovanja i samoefikasnosti u usporedbi s ispitanicima iz kontrolne skupine ispitanika iz opće populacije. U istraživanju je sudjelovalo 176 ispitanika podijeljenih u dvije skupine. Ispitivanu skupinu (74 ispitanika) činili su pacijenti hospitalizirani u Klinici za psihijatriju KBC-a Rijeka, a kontrolna skupina (102 ispitanika) izabrana je iz uzorka opće populacije. Svi ispitanici su popunili sljedeće upitnike: Rosenbergovu ljestvicu samopoštovanja i Ljestvicu opće samoefikasnosti, dok su pacijenti popunili i Upitnik o procjeni samostigmatizacije, konstruiran samo za potrebe ovog istraživanja. Oboljeli od duševnih bolesti iskazali su statistički značajno nižu razinu samopoštovanja i samoefikasnosti u odnosu na opću populaciju. Dobiveni rezultati pokazali su statistički značajnu, negativnu korelaciju između stupnja samopoštovanja i samoefikasnosti u odnosu na percipiranu samostigmatizaciju. Znači, ispitanici s nižim rezultatima na samopoštovanju i samoefikasnosti imaju izraženije samostigmatizirajuće stavove. Takvi stavovi su refleksija društvenih stereotipa prema osobama s mentalnim bolestima te njihovog prihvaćanja i primjene od duševnih bolesnika, što su preduvjeti nastanka samostigme. Samostigmatizacija ima dalekosežne posljedice na kvalitetu života, životnu funkcionalnost te socijalne i društvene interakcije pogođenih pojedinaca.The aim of this paper was to examine the self-stigmatizing attitudes of the examinees from the group of mentally ill patients and determine their level of self-esteem and self-efficacy while comparing their results with those of examinees from the control group from the general population. 176 participants were included in this research and divided into two groups. The first group (74 subjects) consisted of patients hospitalized at the Psychiatric Department of the Clinical Hospital Centre Rijeka and the second, control group (102 subjects) was selected from a sample of the general population. The respondents were given a questionnaire that consisted of the Rosenberg Self-Esteem Scale and the General Self-Efficacy Scale, while psychiatric patients were also given the questionnaire for assessing self-stigmatization which was designed for the purpose of this research. The first group (psychiatric patients) has statistically significantly lower levels of self-esteem and self-efficacy than the examinees from the general population. Our results show statistically significant negative correlation between the degree of self-esteem and self-efficacy in relation to perceived self-stigmatization. Those participants with lower levels of self-esteem and self-efficacy have more self-stigmatizing attitudes. These attitudes reflect the stereotypes about people with mental illness present in society and subsequently the acceptance and application of those stereotypes by the psychiatric patients, which are the preconditions for self-stigma. Self-stigmatization has farreaching consequences on the quality of life, life functionality, and the social interaction of affected individuals

SEXUAL DIFFERENCES AND GROUP PROCESS: THE INFLUENCE ON EXPRESSING DESIRES

Pod željom se podrazumijeva subjektivni aspekt i motivacijska snaga koja, osim seksualnog, prožima sve sfere ljudskog života. Kada je u pitanju izražavanje želje u grupi, ne misli se isključivo na seksualnu želju. Seksualni odnosno rodni identitet u grupi, a osobito kad su u pitanju seksualne različitosti, utjecat će na način izražavanja želje u grupi. U kojoj će mjeri članovi grupe biti u stanju izraziti želje u grupi ovisi o više čimbenika povezanih s članovima grupe ili voditeljem kao i sa samom grupom. O sličnim čimbenicima ovisi i tko će biti objekt želje: drugi član u grupi, voditelj ili grupa kao cjelina. Teme koje se odnose na seksualnost, osobito seksualne različitosti, teško su dostupne u grupnom procesu, budući da se seksualnost drži osobnom temom, često uz prateći osjećaj krivnje i srama. Valjana rasprava na temu seksualnosti često izostaje, osobito kad je u pitanju seksualna različitost. Na taj način otvara se prostor predrasudama, a vrlo često i nepotrebnoj stigmi ili pak patologizaciji određenih seksualnih obilježja koja su često samo različitosti nekog od seksualnih odnosno rodnih identiteta. U posljednje vrijeme dolazi do znatnog napretka u prihvaćanju seksualnih različitosti i na društvenom planu i na planu grupne terapije. Bez obzira na koji način se pristupa pitanjima seksualnih različitosti u terapijskoj grupi, seksualne različitosti prisutne su i utječu na većinu aspekata grupnog procesa. Zadaća grupnih terapeuta jest suočiti se s promjenama na planu seksualnih različitosti i prilagoditi vlastita moralna načela kako bi grupa postigla koheziju i kako bi svaki član grupe bio u prilici izraziti želje „ovdje i sada“, uključujući i one seksualne prirode, bez obzira na seksualne različitosti.Desire includes a subjective aspect and a motivational force which, apart from the sexual, pervades all spheres of human life. When it comes to expressing a desire in a group, this cannot be merely brought down to sexual desire. Sexual identity, or gender identity, in a group will affect the way the desire is expressed, and especially so when diverse sexualities are involved. The degree to which the members of a group will be able to express their desires in the group depends on a number of factors that may concern either the members, the conductor, or the group itself. Similar factors determine who the object of the desire will be: another member, the conductor, or the group as a whole.Topics pertaining to sexuality, especially when sexual differences are in question, are difficult to approach in a group process since sexuality is considered to be a personal thing, often accompanied by feelings of guilt or shame. Healthy discussions on the topic are often not held, especially concerning sexual differences. This way, a path opens towards prejudice and unnecessary stigma or pathologization of certain sexual features that are oftentimes just variations of some of sexual or gender identities. In recent times, we have seen a significant development in acceptance of sexual differences, as in society so in group therapy. Irrespective of the approach to the issues of sexual differences in a therapy group, sexual differences are present and affect most aspects of the group process. The task of group therapists is to face the changes concerning sexual differences and to adjust their own moral principles in order for the group to attain cohesion. Consequently, every member of the group would have the opportunity to express their desires “here and now”, including those of sexual nature, regardless of sexual differences

Family and chronic illness

Suvremena medicinska praksa suočena je s porastom broja oboljelih od kroničnih bolesti. Kronična bolest utječe na ustaljenu dinamiku obitelji. Obiteljska dinamika podrazumijeva tip i model obitelji, značenja, vjerovanja i rituale, fazu životnog ciklusa u kojoj se obitelj nalazi u trenutku suočavanja s kroničnom bolešću te osnovne aspekte funkcioniranja koji uključuju kohezivnost, prilagodljivost, komunikaciju i organizaciju obitelji. Kronični bolesnici, kao i članovi njihove obitelji, dotadašnji način života moraju prilagoditi zahtjevima bolesti, uključujući i psihološku prilagodbu. Kod članova obitelji suočenih s bolešću jednog svojeg člana u početku dominira negacija, slijedi depresivna faza i žalovanje te polako nastupa prihvaćanje, čime se dotadašnji odnosi zamjenjuju odnosima druge kvalitete. Funkcionalna obitelj je fleksibilna i u stanju je prilagoditi svoju dinamiku kako bi pronašla mjesta za bolest uz istovremeni rad na ciljevima, rutini i ritualima koje je imala i prije pojave bolesti. U proces liječenja kronične bolesti neophodno je aktivno uključiti članove obitelji. Studije su pokazale da liječenje kroničnih bolesti orijentirano obitelji predstavlja unaprjeđenje u liječenju u odnosu na tradicionalno liječenje orijentirano na bolest ili pojedinačnog bolesnika, kako po pitanju rezultata liječenja i ishoda bolesti tako i u odnosu na ekonomske kriterije.Modern medical practice is faced with increasing number of people with chronic diseases. Chronic illness affects standard family dynamics. Reaction of the family faced with a chronic illness of their member depends on the unique balance of family members and relations between them. Family dynamics refers to the type and model of the family, meanings, beliefs and rituals, life cycle stage in which the family is at the time of dealing with chronic disease as well as basic aspects of functioning including cohesiveness, adaptability, communication and organization of the family. Chronic patient, and his family members, have to adapt their former way of life to the demands of illness, including psychological adjustment. In a family which is faced with the disease of one of its members initially dominates negation, the next phase is depression and mourning, then they slowly accept the situation and it replaces the former relations with new quality relations. Functional family is flexible and is able to adapt their dynamics to find space for a disease with simultaneous work on the goals, routines and rituals that it had before the incidence of the disease. In the process of chronic diseases treatment, it’s necessary to actively involve family members. Studies showed that family-oriented treatment of chronic diseases is an improvement in treatment over traditional treatment of a disease-oriented or individual- oriented treatement, both regarding the results of treatment and outcome of disease and in relation to economic criteria

Family and chronic illness

Suvremena medicinska praksa suočena je s porastom broja oboljelih od kroničnih bolesti. Kronična bolest utječe na ustaljenu dinamiku obitelji. Obiteljska dinamika podrazumijeva tip i model obitelji, značenja, vjerovanja i rituale, fazu životnog ciklusa u kojoj se obitelj nalazi u trenutku suočavanja s kroničnom bolešću te osnovne aspekte funkcioniranja koji uključuju kohezivnost, prilagodljivost, komunikaciju i organizaciju obitelji. Kronični bolesnici, kao i članovi njihove obitelji, dotadašnji način života moraju prilagoditi zahtjevima bolesti, uključujući i psihološku prilagodbu. Kod članova obitelji suočenih s bolešću jednog svojeg člana u početku dominira negacija, slijedi depresivna faza i žalovanje te polako nastupa prihvaćanje, čime se dotadašnji odnosi zamjenjuju odnosima druge kvalitete. Funkcionalna obitelj je fleksibilna i u stanju je prilagoditi svoju dinamiku kako bi pronašla mjesta za bolest uz istovremeni rad na ciljevima, rutini i ritualima koje je imala i prije pojave bolesti. U proces liječenja kronične bolesti neophodno je aktivno uključiti članove obitelji. Studije su pokazale da liječenje kroničnih bolesti orijentirano obitelji predstavlja unaprjeđenje u liječenju u odnosu na tradicionalno liječenje orijentirano na bolest ili pojedinačnog bolesnika, kako po pitanju rezultata liječenja i ishoda bolesti tako i u odnosu na ekonomske kriterije.Modern medical practice is faced with increasing number of people with chronic diseases. Chronic illness affects standard family dynamics. Reaction of the family faced with a chronic illness of their member depends on the unique balance of family members and relations between them. Family dynamics refers to the type and model of the family, meanings, beliefs and rituals, life cycle stage in which the family is at the time of dealing with chronic disease as well as basic aspects of functioning including cohesiveness, adaptability, communication and organization of the family. Chronic patient, and his family members, have to adapt their former way of life to the demands of illness, including psychological adjustment. In a family which is faced with the disease of one of its members initially dominates negation, the next phase is depression and mourning, then they slowly accept the situation and it replaces the former relations with new quality relations. Functional family is flexible and is able to adapt their dynamics to find space for a disease with simultaneous work on the goals, routines and rituals that it had before the incidence of the disease. In the process of chronic diseases treatment, it’s necessary to actively involve family members. Studies showed that family-oriented treatment of chronic diseases is an improvement in treatment over traditional treatment of a disease-oriented or individual- oriented treatement, both regarding the results of treatment and outcome of disease and in relation to economic criteria

PSYCHODYNAMIC GROUP PSYCHOTHERAPY IN THE TREATMENT OF BORDERLINE PERSONALITY DISORDER

Granični poremećaj osobnosti karakteriziran je pervazivnim simptomima nestabilnosti u međuljudskim odnosima, self-imageu i afektu, uz impulzivnost i znatne probleme s identitetom. Socijalno ponašanje tih bolesnika nestabilno je, kaotično i kontradiktorno. Liječenje graničnog poremećaja osobnosti predstavlja terapijski izazov budući da navedena obilježja osobnosti tih bolesnika znatno utječu na odnos prema psihoterapeutu kao i na odnose u grupnom settingu. U vrijeme kada su postavljeni dijagnostički kriteriji za granični poremećaj smatralo se da je riječ o poremećaju koji je neizlječiv. U međuvremenu je došlo do promjene u konceptu, stajalištima i psihoterapijskom pristupu. Istraživanja evaluacije psihoterapijskih postupaka za taj poremećaj dokazala su učinkovitost mnogih od njih. Među njima je i grupna psihodinamička psihoterapija. U odnosu na klasični psihoanalitički pristup u radu s tim bolesnicima danas se preferira veći angažman psihoterapeuta, ohrabrivanje, validacija i savjetovanje, tj. potiče se intersubjektivnost i enactment, osobito na početku liječenja kad je anksioznost preplavljujuća i postoji opasnost od preranog prekida terapije. Nakon što se postigne kohezija u grupi i razvije grupni matriks dolaze u obzir ekspresivne ili interpretativne intervencije. Budući da je riječ o bolesnicima koji psihoterapeuta ne ostavljaju indiferentnim te mogu pobuditi snažne kontratransferne odgovore, potrebna je redovita supervizija. Cilj ovog rada jest teoretsko razmatranje i razumijevanje uloge grupne psihodinamičke psihoterapije u liječenju graničnog poremećaja osobnosti.Borderline personality disorder (BPD) is characterized by pervasive symptoms of instability in interpersonal relations, self-image, and affect, accompanied by impulsive behavior and major identity issues. Social behavior of such patients is unstable, chaotic, and contradictory. The treatment of BPD is a challenge from the therapeutic point of view since the patient personality traits mentioned above affect the relationship with both the psychotherapist and the group, if treated in such setting. At the time when the diagnostic criteria were being set, BPD was considered to be an incurable disorder. In the meantime, there have been changes made to the concept of BPD, to the attitudes toward it, as well as to the therapeutic approach. Evaluations of psychotherapeutic methods showed that many were effective, including group psychodynamic psychotherapy, for BPD treatment. In contrast to the classical psychoanalytic approach, greater psychotherapist involvement is advised, as well as encouragement, validation, and counseling. The BPD patients are being motivated to use intersubjectivity and enactment, especially in the initial sessions when anxiety can be overwhelming and there is a risk of premature termination of the therapy. After the group cohesion has been achieved and the group matrix developed, expressive or interpretative interventions can be employed. Due to the risk of strong countertransference, regular supervision must be practiced. The aim of this paper is to present some theoretical considerations and deepen the understanding of the role of psychodynamic group psychotherapy in the treatment of BPD patients

POSTTRAUMATIC STRESS DISORDER AND COMORBID SEXUAL DYSFUNCTIONS

The rates of sexual dysfunctions among patients with PTSD are much higher than in the general population. An increasing body of scientific research has confirmed clinically relevant sexual problems (Letourneau et al. 1997, Kotler et al. 2000, Hossain et al. 2013, Yehuda et al. 2015, Tran et al. 2015), among which erectile dysfunction (ED) and premature ejaculation (PE) were the most frequent (Letourneau et al. 1997). It is important to underline that patients, particularly military veterans with PTSD, have an increased risk of sexual dysfunction independent of the use of psychiatric medications (Benjamin et al. 2014). Considering the utilization of pharmacotherapy, data indicate that over 80% of the veterans treated for PTSD in the USA have been receiving at least one of the psychotropic medications (Bernardy et al. 2012). A drug utilization study conducted in Croatia revealed that the annual frequency of drug use among pharmacologically treated PTSD patients was the highest for anxiolytics (75.83% patients), antidepressants (61.36%), hypnotics (35.68%) and antipsychotics (30.21%) in 2012 (LeticaCrepulja et al. 2015). In this context, it is very important to highlight that a variety of psychotropic medications recommended for the treatment of PTSD can induce sexual function disorders (Clayton & Shen 1998, Labbate 2008). Most practice guidelines for the treatment of PTSD highlight antidepressants as the first-line pharmacotherapeutic agents, particularly selective serotonin reuptake inhibitors (SSRIs) (Ballenger et al. 2000, American Psychiatric Association 2004, National Institute for Clinical Excellence (NICE) 2005, Baldwin et al. 2005, Forbes et al. 2007) and serotonin-norepinephrine reuptake inhibitors (SNRIs) (Bandelow et al. 2008, Benedek et al. 2009, Stein et al. 2009, Department of Veterans Affairs 2010, World Health Organization 2013, Baldwin et al. 2014). Since the introduction of these medications, increasing attention has been given to the side effects, such as sexual dysfunction (Labbate 2008, Corona et al. 2009, Serretti & Chiesa 2011). SSRIs can negatively affect all domains of sexuality (desire-arousal-orgasm-resolution) (Corona et al. 2009). A study of sexual functioning in war veterans with posttraumatic stress disorder conducted in Croatia showed that these patients had less sexual activity, hypoactive sexual desire and more frequent ED compared with healthy volunteers. These problems might be associated with the antidepressant therapy (Antičević & Britvić 2008). Another Croatian study revealed that the population exposed to traumatic event(s) had the same level of sexual functioning (or the same incidence of sexual dysfunction) regardless of the absence or presence of PTSD symptoms and their severity (Arbanas 2010). The aim of this report was to present a patient with PTSD and comorbid sexual dysfunctions