Need and responsiveness in the treatment of a severely traumatized patient: a relational perspective

Severely traumatized patients may exhibit poor functioning and a great deal of dependence upon the therapist. The question is raised as to what such patients truly need from a therapist, and the concept of optimal responsiveness is described. These patients may display complex blends of deficits, resulting from inadequate structuralization, together with pathological internal representations. Their expressed needs in therapy may be true requirements and/or expressions of wishes to be compensated for past suffering and refusal to assume adult functioning. Discerning what might constitute optimal responsiveness to true needs may be further complicated by the propensity some of these patients have for dysfunctional and impulsive behavior. A case is presented that illustrates some of the difficulties in determining how to respond to intense expressions of need, including needs for constant availability of the therapist and for physical contact. It is concluded that although this patient did not need everything from the therapist that she initially thought that she did, her needs were so great that an outpatient treatment situation often seemed insufficient. Despite an overall positive outcome for the patient, the treatment experience was very difficult for the therapist.