An Object Relations Perspective on Emergency Psychiatry

The applications of psychoanalytic theory extend well beyond the therapy room, showing relevance across clinical settings, especially when considering the salience of object relations models and how they inform encounters. Such a lens can be applied to acute care, including in the psychiatric emergency room, where oftentimes patients can present with heightened affect and significant symptom burden, which can flood providers with a great amount of unmetabolized content. This is of particular note in patients with traumatic backgrounds, which can inform very hostile object relations templates. The provider may be positioned in a paradoxical role to be either savior or abuser in such cases, and the potential for retraumatization can be high, especially when countertransference responses are strong and unchecked. This paper will draw primarily from object relations literature to provide a psychodynamic framework for acute care psychiatric settings, underlining the communicative nuances with seemingly recalcitrant or ‘difficult’ patients, as well as the psychodynamic underpinnings of self-injurious behaviours. Case vignettes illustrating the dynamics discussed will be presented.