Identity problems in clinical psychiatry practice


Many people struggle with issues of identity: who they are and their place in the world. For psychiatrists, focusing on identity problems can help patients to progress in psychotherapy and become “more adaptive, integrated versions of themselves,” according to a Perspectives article in the November/December issue of Harvard Review of Psychiatry.

John R. Peteet, MD, of Harvard Medical School and Brigham and Women’s Hospital, Boston, reviews four types of identity problems commonly seen in psychotherapy. Addressing identity issues can shift the focus of therapy away from pathology, “making it easier for the therapist and patient to see therapy as relevant to his or her whole life and aspirations.”

Focus on identity: Helping patients ‘to feel known and seen’

Identity is a powerful concept in psychology as well as culture. “[A] developed identity is marked by a sense of cohesion and continuity with respect to one’s origins, identifications, boundaries, and commitments to oneself and others, coupled with a sense of purpose or calling,” according to Dr. Peteet. However, psychiatrists have lacked a framework for approaching identity issues in clinical practice and for understanding how doing so can add to the process of psychotherapy.

“Identity is often a relevant therapeutic focus because people want to be understood and respected for who they are and have been—fully, not just viewed in terms of their symptoms, diagnosis, cognitive style, or social context—and to be helped to become more adaptive, integrated versions of themselves,” Dr. Peteet writes. He focuses on four of the most common types of identity problems.

Patients with identity diffusion have trouble developing a stable, integrated sense of self. Dr. Peteet observes, “Difficulties in knowing who they are over time lead to problems particularly with intimate relationships. Helping patients to see the things that have always been most important in their lives can help them to understand the reasons for their moods and to develop social learning and trust in others.”

Other patients have identity distortion, with persistently distorted concepts of themselves. They may feel that they are not the persons that other people see, including the therapist—hindering their progress in psychotherapy. Addressing the factors that contribute to identity distortion—for example, depression or substance abuse—may help patients to develop a more realistic sense of their self-worth.

Certain life events can lead to threatened identity. For example, patients faced with a serious illness or disability may fear they are losing “an important part of who they are,” leading to demoralization and existential distress.  Encouraging patients to explore their key values may help them to see who they continue to be, while acknowledging the loss of valued aspects of themselves.

Patients with difficulty integrating identity may experience distressing problems in attempting to reconcile different parts of themselves, sometimes related to conflicts with traditional religious beliefs and practices. Such patients may need help exploring their values and identifications, such as conflicted relationships with parents or the personal meaning of their religious identities.

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