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Republic of the Philippines University of Northern Philippines Tamag, Vigan City College of Nursing A Movie Analysis of Sybil (1976)

In partial fulfilment Of the requirements Of the subject NCM 105: Care of Mother and Child with Maladaptive Behavior

Presented to: JOSEFINA A. FLORENDO, RN MAN Subject Instructor Presented by: Girlie S. Bergonia Janela C. Caballes Mckinley Cabuena Charmie Angel Cardenas Jennifer Javier Claudine Jaramillo Harold Yves Madriaga Mhia Marhee Mercado Michelle Raqueo Kevin Leigh Sta. Ana Hermie Rose Tapuro Nova Rocely Viorge (BSN-III DAFFODIL) JANUARY 2012

TABLE OF CONTENTS

I. II. III. IV.

Title

.. .

Characters

Plot ... Communication Techniques A. Therapeutic Techniques ..

B. Non-Therapeutic Techniques . V. VI. VII. VIII. Defense Mechanism Disoreders Presented ... ...

Interventions/ Management/ Treatment . Reaction and Significance to nursing practice

I.

Title: SYBIL Dr. Cornelia Wilbur the psychiatrist who worked with Sybil for 11 years till she finally made Sybil into a sane person by gathering together her personalities and integrate them as one in Sybils persona. played by Joanne Woodward Sybil Dorsett the lady who developed Multipersonality Disorder due to psychological and physical abuse made by her mother. played by Sally Field Richard J. Loomis the neighbour boyfriend of Sybil played by Brad Davis Hattie Dorsett the mother of Sybil who was actually diagnosed with Paranoid Schizophrenia played by Martine Bartlett Dr. Quinoness the pediatrician whom the mother of Sybil had consulted regarding Sybils health which revealed abuse and violence. He never spilled the beans to anyone not until he met Dr. Wilbur. played by Charles Lane Grandma Dorsett the grandmother of Sybil played by Jessamine Milner Willard Dorsettt the father of Sybil played by William Prince Miss Penny the co-teacher of Sybil played by Penelope Allen

II. Characters:

Other personalities of Sybil: Sybil Isabel Dorsett (1923), the main personality Victoria Antoinette Scharleau (1926), nicknamed Vicky, self-assured and sophisticated young French girl Peggy Lou Baldwin (1926), assertive, enthusiastic, and often angry Peggy Ann Baldwin (1926), a counterpart of Peggy Lou but more fearful than angry Mary Lucinda Saunders Dorsett (1933), a thoughtful, contemplative, and maternal homebody Marcia Lynn Dorsett (1927), an extremely emotional writer and painter Vanessa Gail Dorsett (1935), intensely dramatic Mike Dorsett (1928), one of Sybil's two male selves, a builder and a carpenter Sid Dorsett (1928), the second of Sybil's two male selves, a carpenter and a general handyman Nancy Lou Ann Baldwin (date undetermined), interested in politics as fulfillment of biblical prophecy and intensely afraid of Roman Catholics Sybil Ann Dorsett (1928), listless to the point of neurasthenia Ruthie Dorsett (date undetermined), a baby and one of the less developed selves Clara Dorsett (date undetermined), intensely religious and highly critical of Sybil Helen Dorsett (1929), intensely afraid but determined to achieve fulfillment Marjorie Dorsett (1928), serene, vivacious, and quick to laugh The Blonde (1946), a nameless perpetual teenager with an optimistic outlook

III.

Plot The drama movie Sybil was based on the book by Flora Rheta Schreiber. Sally Field portrayed the title character. Sybil Dorsett, a young artist from Willow Corners, Wisconsin who is employed as a substitute teacher while she works on her M.A. degree in New York City, has developed multiple personality disorder. She has periodic blackouts that last anywhere from a few minutes to a few years. An episode that began in front of her young students in a park, ended several hours later in Sybil's apartment with her wrist cut, and a drawing of a swinging light bulb on her artist easel. She ends up in the clinic where Dr. Wilbur appeared to give her a neurological examination. During the smell test, Sybil is visibly disturbed at the scent of disinfectant that led Sybil to have a blackout. Sybil admits to having blackouts and fears they are getting worse. Dr. Wilbur theorizes that the incidents are a kind of hysteria, all related to a deeper problem. As Wilbur explores her life, she finds she was raised by a very strict fundamentalist Christian minister and his paranoid schizophrenic wife in a small town. Her father attempted to ignore it, as did the local paediatrician. Her father did not believe either Sybil or her mother was ill. Sybil was emotionally, sexually and physically abused by a mother who was convinced in her paranoia that she was sending her to heaven. The mother used an enema to force water into her and then forced her to "hold" it until the mother finishes the last note she was playing in the piano. She inserted knives, button hooks, etc., into her vagina. She called to her to come for affection, and then tripped her to fall down the stairs. She locked her in a wheat bin in the barn and left her for dead. Sybil ends up spending years in therapy with Dr. Wilbur, a psychoanalytic psychotherapist, who uses mind-altering drugs, hypnosis and dream analysis to uncover her Multiple Personality Disorder (now known in the DSM-IV-TR as Dissociative Identity Disorder). She has tens of personalities, from little boys to adult women of greater and lesser ability to function. Various personalities come and go, each with his/her own talents and abilities, to get her through difficult situations (in her case, a simple date or caring for children in her work as a substitute). The most competent is Vicky, who speaks with a French accent. Sybil, the executive personality, is not fully aware of the "others" (the alter egos), so she is often confused and loses blocks of unaccounted-for time.

By this time Sybil is becoming friends with a male neighbor, Richard, a young widower with a small son, Matthew, who seems to be very taken with her. Sybil continues to see Richard and their relationship progresses. On Christmas Eve, Sybil agrees to let Richard stay the night, Sybil has a nightmare in which she is being pursued by a decapitated cat and ends up climbing to the top of her bookcase, waking Richard. While Richard is calling Dr. Wilbur, Marcia emerges and attempted to commit suicide by jumping off the roof of the apartment. Dr. Wilbur arrives to find Richard has just rescued Sybil from an attempt to jump off the roof. While under the effects of the sedative, she babbles about being in love with Richard and does not want to see him until she gets herself together. Sybil comes home one day and sees Richard's apartment is empty. Sybil feels deserted. Sybil arrives for an appointment and tells Dr. Wilbur it's all been a lie, that she does not have multiple personalities. She states that she had been putting on an act all along and that her mother never abused her. Dr. Wilbur is not sure she believes Sybil, but thinks this may be the beginning of her healing in that the personalities are coming together as one. Dr. Wilbur decides to take an investigatory trip to Chicago to speak to Sibyls father, and then to Sybils hometown in Wisconsin and visits Sibyls pediatrician, Dr. Quinoness. The pediatrician remembers Sybil well, and her nervous mother, and shares his records with Dr. Wilbur. The medical records are indicative of the abuse that Sibyl had described. Dr. Quinoness gives Dr. Wilbur a frightening account of extensive scar tissue he found while examining Sybil for a bladder problem, knowing the whole time that the only way it could be caused is from abuse. He is beset with guilt for not having taken action to protect Sybil from abuse. The film ends with Dr. Wilbur taking Sybil on a picnic in a secluded area, encouraging her to paint, when she cannot paint. Dr. Wilbur performs hypnosis on Sybil, it is then that Sybil meets the rest of her personalities and they become one. Through Wilbur's psychotherapy, she is able to "integrate" and eventually become a college professor of art. She and Wilbur remained friends.

IV.

Communication techniques a. Therapeutic

SITUATION On a clinic, Dr. Wilbur was performing a neurological exam when suddenly Sybil mentioned about the doctors white coat with fear in her eyes and voice.

DOCTOR-PATIENT COVERSATION Sybil: I see white coat Dr. Wilbur: Whats the matter? Does my white coat bother you?

TECHNIQUE AND RATIONALE EXPLORING Dr. Wilbur was trying to know the reason why Sybil fear white coat. ATTEMPTING TO TRANSLATE WORDS INTO FEELINGS Dr. Wilbur was trying to put into words the feelings Sybil expressed only indirectly. **The feeling of fear is due to a traumatic encounter with a dentist during her childhood.

After the incident in the park with the kids, Sybil was admitted on the clinic of Dr. Wilbur, a psychiatrist. While having a conversation, Sybil talked like a kid in which Dr. Wilbur had verbalized. Then, the conversation goes until the neurologic exam was finished.

Dr. Wilbur: Is it fun talking like a little girl, Ms. Dorsett? Sybil: What? (startled) Dr. Wilbur: What just happened? Jet lag? Sybil: I cut my wrist. Dr. Wilbur: Thats right. Why, dont you remember? Sybil: Yes, of course. Im in New York. Im in a hospital. I cut my wrist. Mind you if I go? Dr. Wibur: Aha. (nodding)

PRESENTING REALITY Dr. Wilbur was trying to make Sybil aware of her behaviour in order to bring her back to reality.

OFFERING GENERAL LEADS Its a sign that the doctor is interested, thus making Sybil to go on talking.

Sybil: Mind you. May I go. Dr. Wilbur: Id like to finish the neurological exam. Sybil: Why is it that there is a neurologic exam? I cut my wrist. I think you have the charts mess up Dr. Wilbur: It just seemed when the surgical resident was patching

GIVING INFORMATION Dr. Wilbur was trying to

you up, you seem to be confused, provide information to Sybil in so they called me. And I asked, order for her not to be how could I help you, you took bothered. my hand. You came over here. Dont you understand? Still on that same day, on Dr. Wilburs office, Sybil suddenly said yes while Dr. Wilbur was busy writing on her chart. Sybil: Im sorry. Did you ask me something? Dr. Wilbur: No. Youve been just telling me about your symptoms. Your ah tunnel vision and your bumping into walls. Sybil: Yes. Yes, I know. Sometimes, when Im heading for the door, my mistake of (blocked) Dr. Wibur: What is it? Sybil: This is your office?

EXPLORING Dr. Wilbur was helping Sybil to continue her statement in order to explore what shes heading to.

Dr. Wilbur: Yes. (nodding) (silence. Sybil was pouting and bowing her head away from doctors eyes.) Later, Sybil was still in Dr. Wilburs office till she speaks up what she was supposed to say a while ago. Dr. Wilbur: No. Without looking at your watch. Tell me what you just said. Sybil: Is it so important? Dr. Wilbur: Yes. Sybil: I said, is this your office? Dr. Wilbur: That just what happened an hour ago. Its night time now.

OFFERING GENERAL LEADS To let Sybil continue what she was talking about.

PRESENTING REALITY Dr. Wilbur was making Sybil aware that she couldnt remember what just happened any moment ago at her office. **She prevented Sybil of looking to her watch in order for her not to formulate what she must have told an hour ago. SEEKING CLARIFICATION Dr. Wilbur was trying to verify if Sybil doesnt really remember anything. But

Sybil: I didnt want you to know. Dr. Wilbur: Yes, you did. Sybil: Nobody knows. Dr. Wilbur: Somebody knows now. Alright? Do you remember

anything? Sybil: (shook her head) Dr. Wilbur: Do you remember the vocabulary test, with so many of that? Sybil: No. I dont. (shook her head) Dr. Wibur: You dont know why youve been here for an hour or a day or week, do you? On that same night at Dr. Wilburs office, Sybil was telling more of her sentiments to Dr. Wilbur. Sybil: Pls. dont touch me. It hurts me. Dr. Wilbur: It hurts to be touched? Here. Have a crying towel.

eventually, she did some.

RESTATING To let Sybil know whether her expressed statement was understood. **The hurt feeling was brought about by the physical abuse of her mother.

Dr. Wilbur: You know, I think the fear that youre suffering from is very very deep and I think your, your symptoms, your tunnel vision and your blackouts are the result of that fear. Its a kind of hysteria. You see? Sybil: Yes.

GIVING INFORMATION To inform Sybil that her symptoms are brought about by fear to someone or something. That blackout is a defense mechanism when you are too scared to face something. Thus it makes sense to blackout in order not to know what youre scared of. EXPLORING Dr. Wilbur knows Sybils conversation with her father had scared her in the sense that she blocked out again. Thats why she wants to explore what happened and how was it induced. **She feared her father scolding her because he want her to engage to any doctors work because he hated them for diagnosing his wife of Paranoid

Dr. Wilbur received a call from Vicki, one of Sybils personalities, asking her to come over to Sybils apartment because she was about to jump off the building because the things that embarrassed and feared her keeps flashing back on her mind.

Sybil: I lost my job and I tried to ask my, my(blocked) Dr. Wilbur: Yeah. You asked your father about seeing me. What happened? What did he say?

Schizophrenia. She felt her father doesnt care about her condition. When Dr. Wilbur was already on Sybils place, she saw her standing over a widely opened window, as if she was about to jump. Calling her Sybil brought her to reality. Then when she was talking about her father, she suddenly blocked out again and changed into Peggys personality. Shes freaking out and talking about the people whom she fears. After some months, Vicki visited Dr. Wilbur at her office. At first, Dr. Wilbur was bewildered but she just let her in and accepted her as if they knew each other for so long. Sybil: Theyre everywhere. No. Pls. dont make me go there. Dr. Wilbur: Its not happening now. PRESENTING REALITY Dr. Wilbur was trying to get Sybil out of mind. That what shes thinking was not the reality. **This time, Dr. Wilbur found another personality of Sybil. She transformed into Peggy in order to cope with the stress brought about by the embarrassment in the park and the disinterest of her father towards her condition. Dr. Wilbur: Tell me. Are you related in some ways? All of you? Sybil(Vicki): I know where I am. I am in New York. Lots to do in museum, to go to concert Dr. Wilbur: I think that Sybil and Peggy have the same mother and father. So how are they related? Are they sisters? Or are you all part of the same person? Sybil: Dont be silly. It cant be that. EXPLORING After the incident at Sybils apartment, Dr. Wilbur started to suspect Multipersonality Disorder so she tried to extract information from Vicki whom she believe was very controlled of herself and selfassured. **This encounter answered Dr. Wilburs question. Sybil blocked out because of embarrassment. Vicki also told that Sybil is a lamentable person who wanted to paint and play the piano but she cant. Shes even afraid of people especially hands, making Dr. Wilbur suspect that Sybils mother was not an angel.

b. Non-therapeutic SITUATION DOCTOR-PATIENT COVERSATION TECHNIQUE AND RATIONALE

V.

Defense Mechanisms a. Denial Denial is the refusal to accept reality or fact, acting as if a painful event, thought or feeling did not exist. It is considered one of the most primitive of the defense mechanisms because it is characteristic of early childhood development. In the movie, Sybil was denying that she and her different personalities is one when she had her psychiatric interview. b. Regression Regression is the reversion to an earlier stage of development in the face of unacceptable thoughts or impulses. For an example an adolescent who is overwhelmed with fear, anger and growing sexual impulses might become clingy and start exhibiting earlier childhood behaviours he has long since overcome, such as bedwetting. In the movie Sybil, she had instances of being childish like nail biting, slumping/slouch in the sofa and infant position when sleeping and sucking hen the personality of Baby Ruthie emerges. c. Acting Out Acting Out is performing an extreme behaviour in order to express thoughts or feelings the person feels incapable of otherwise expressing. A person who acts out may instead throw a book at the person, or punch a hole through a wall. When a person acts out, it can act as a pressure release, and often helps the individual feel calmer and peaceful once again. Sybil was very angry and attempted to hurt her father when she said that she will go to have a therapy. Moments of coming from a

black out while in the apartment, she will often find furnitures turned upside down and the room in complete disarray. d. Dissociation Dissociation is when a person loses track of time and/or person, and instead finds another representation of their self in order to continue in the moment. A person who dissociates often loses track of time or themselves and their usual thought processes and memories. People who have a history of any kind of childhood abuse often suffer from some form of dissociation. In extreme cases, dissociation can lead to a person believing they have multiple selves (multiple personality disorder). People who use dissociation often have a disconnected view of themselves in their world. Time and their own self-image may not flow continuously, as it does for most people. In this manner, a person who dissociates can disconnect from the real world for a time, and live in a different world that is not cluttered with thoughts, feelings or memories that are unbearable. Sybil has the multiple personality disorder and presented a total of these personalities. Her first account of dissociation was during her childhood when her mother abused her. She dissociated and just came back as Sybil during the 7th grade. She even find things or possession not originally belonged to her. e. Projection Projection is the misattribution of a persons undesired thoughts, feelings or impulses onto another person who does not have those thoughts, feelings or impulses. Projection is used especially when the thoughts are considered unacceptable for the person to express, or they feel completely ill at ease with having them. For example, a spouse may be angry at their significant other for not listening, when in fact it is the angry spouse who does not listen. Projection is often the result of a lack of insight and acknowledgement of ones own motivations and feelings. Vicky, one of the personalities of Sybil, always project that Sybil has a problem. f. Displacement Displacement is the redirecting of thoughts feelings and impulses directed at one person or object, but taken out upon another person or

object. People often use displacement when they cannot express their feelings in a safe manner to the person they are directed at Whenever Sybil feels like she need help she always knocks the glass of the window. g. Intellectualization Intellectualization is the overemphasis on thinking when confronted with an unacceptable impulse, situation or behaviour without employing any emotions whatsoever to help mediate and place the thoughts into an emotional, human context. Rather than deal with the painful associated emotions, a person might employ intellectualization to distance themselves from the impulse, event or behaviour. For instance, Sybil who had just been given a terminal medical diagnosis, instead of expressing her sadness and grief, focuses instead on the details of all possible fruitless medical procedures. h. Compensation Compensation is a process of psychologically counterbalancing perceived weaknesses by emphasizing strength in other arenas. By emphasizing and focusing on ones strengths, a person is recognizing they cannot be strong at all things and in all areas in their lives. For instance, when a person says, I may not know how to cook, but I can sure do the dishes!, theyre trying to compensate for their lack of cooking skills by emphasizing their cleaning skills instead. When done appropriately and not in an attempt to over-compensate, compensation is defense mechanism that helps reinforce a persons selfesteem and self-image. Sybil was compensating her fear by socializing using her personality as Vicky to cover up her weaknesses. VI. Disorders Presented (Definition, Causes, and Signs and Symptoms) a. Suicidal Ideation Suicidal ideation is a thought about suicide, which may be as detailed as a formulated plan, without the suicidal act itself. Although most people who undergo suicidal ideation do not commit suicide, some go on to make suicide attempts. In the movie, one personality of Sybil had suicidal ideations. It was showed on the part where she called

Dr. Cornelia Wilbur at the middle of the night telling that she should come immediately because Sybil needs her, exclaiming that Sybil is sitting on the edge of the window. When Dr. Cornelia Wilbur arrived with two security personnel with her, she knew Sybil wasnt playing jokes with her. Sybil was really on the edge of the window situated at the third floor of the building where she was living. The signs and symptoms of this disorder was social isolation, (when sybil wasnt already going to school for work) depression, (when Dr. Cornelia Wilbur approached her, she was executing a fetal position-sign of depression and lack of security). Verbalization of suicidal ideation (when sybil phoned Dr. Cornelia Wilbur signifying her intentions to commit suicide). b. Regression Regression, a defensive reaction to some unaccepted impulses, a part of sybils personality disorders. She showed signs of regression on her role as peggy the little girl. She would always knock on the windows every time she wakes up in the morning. The windows arent intended to be broken. She should just knock on them but as she grows up, her strength improves. So instead of just knocking on the windows, she tends to break them with her bare fists. The signs and symptoms of regression as presented in the movie was first, when sybil was talking to Dr. Woodward for the first time she was covering her one eye, shrugging her shoulders and talks like an elementary age child who cant even communicate well with professionals. The cause of this disorder I think was when Sybils mother submitted her to a tonsillectomy even though Sybil wasnt really diseased! Her knocking on the windows was a cry for help, when the doctor who had done tonsillectomy to her was about to leave. c. Dissociative Identity Disorder Dissociative identity disorder is the presence of two or more distinct identities or personality states that recurrently take control of behavior. In

the movie, Sybil had portrayed thirteen characteristics. The first one is Vanessa. Vanessa holds Sybils musical abilities, plays the piano and helps Sybil pursue a romantic relationship with Richard, Sybils neighbor boyfriend. The next one is Vicky, a 13 year old who speaks French, a very strong, sophisticated and mature personality who knows about and has insight into all the other personalities. The next one is one of the most popular personalities of Sybil, Peggy. She is a 9 year old who speaks like a little girl. Holds Sybil's artistic abilities, often appears while crying hysterically due to Sybil's fears. She has many misconceptions; for instance, she does not know that she is in New York City and, instead, thinks she is in the small town that Sybil grew up. Peggy feels the greatest trauma from her mom's abuse, highlighting the time when her mom accompanied her to a physician and told the physician that Peggys tonsils should be removed. The third personality of Sybil is Marcia, the one who dresses in funeral attire and constantly has suicidal thoughts and attempts suicide. Supposedly tried to kill Sybil in the Harlem hotel but was stopped by Dr. Wilbur. She thinks the end of the world is coming. The fourth personality of Sybil is Mary, Sybil's memory of her grandmother; she speaks walks and acts like a grandmother, and is anxious. Fifth personality of Sybil is Nancy, who kept waiting for the end of the world and was afraid of Armageddon. She's a product of Sybil's dad's religious fanaticism. Ruthie is the sixth personality of Sybil. She is one of Sybil's less developed selves, a baby in fact. When Sybil hears her mom's voice, she is so terrified that she regresses into Ruthie. Ellen, Marjorie and Sybil Ann are the seventh eighth and ninth personality of Sybil which was seldom emphasized in the movie. Though Sybil is a lady, she also had personality disorders which were masculine in nature. The first one is Mike, who built the shelf in the top of Sybil's closet to hide Vickie's paintings, which she does at night. Another masculine personality of Sybil is Sid, who wants to be just like his father, loves to play football. The cause of Sybils multi-personality disorder was purely childhood abuse. She wasnt given sufficient attention by her mother. Attention that is rightful from a mother to her daughter. She would always beat Sybil,

blame her for everything bad that happens and would look into Sybil as a useless, worthless being. Her mother has not even uncovered the kindness inside Sybils heart. All she sees and notes from Sybil is negative and even Sybils positive attitudes, she considers it bad. Even a single mistake of the child Sybil would mean big to her. She would often put Sybil inside a brown sack, tie it on the well and soak Sybil into its waters. Another abuse on Sybils part was the moral abused caused by the religious fanaticism of her father. As an individual, I think I would feel the same way as Sybil had if I were her fathers son. I believe in God I know, but the way Sybils father professes his faith I think is exceeding the definition of a real religious and spiritual beingits too much!

d. Psychodynamics DEPRESSION In the study of disordered behaviour we will find our chief help is the etiologic point of view. In order to keep etiology the centre of investigative interest, we have evolved the working concept of "pathogenic phenotypes." The problem thus posed is to disclose the causative chain of events which produces each of these disease-prone phenotypes as its effect. Genetically, this etiologic chain is a chain of interactions of genotype and environment. We must learn to correlate more effectively clinical observation and material drawn from genetics, pathologic anatomy, physiology, biophysics, biochemistry, and psychodynamics. There can be no true progress unless we leave our cozy pigeon-holes and join forces for the common task. Within this framework we tentatively speak of the "class of mood cynics phenotypes," which is characterized, among other manifestations, by the high incidence of

depressive spells. These depressive spells are the topic of our present symposium. My assignment is to outline their specific psychodynamics which presumably represent the terminal links in the etiologic chain. In the circumstances we must resort to schematic presentation and limit ourselves to the essentials. First we shall sketch the clinical picture of a spell of depression: the patient is sad and in painful tension. He is intolerant of his condition, thereby increasing his distress. His self-esteem is abased, his self-confidence shattered. Retardation of his initiative, thinking, and motor actions makes him incapable of sustained effort. His behaviour indicates open or underlying fears and guilty fears. He is demonstratively preoccupied with his alleged failings, shortcomings, and unworthiness; yet he also harbors a deep resentment that life does not give him a fair deal. He usually has suicidal ideas and often suicidal impulses. His sleep is poor; his appetite and sexual. JANUARY-FEBRUARY, 1951 The desire are on the wane or gone. He takes little or no interest in his work and ordinary affairs and shies away from affectionate as well as competitive relationships. All in all, he has lost his capacity to enjoy life. He is drawn into a world of his own imagination, a world dedicated to the pursuit of suffering rather than to the pursuit of happiness. Such attacks may be occasioned by a serious loss, failure, or defeat; or may seem to come from the clear blue sky. Their onset may be sudden or gradual; their duration, from a few days or weeks to many months. Their severity ranges from mildly neurotic to fully psychotic. Often in the neurotic and almost always in the psychotic cases there are conspicuous physical symptoms, such as loss of weight and constipation. In some patients spells of depression alternate with spells of elation while in others no spells of elation occur. The depressive spell has a hidden pattern of meaning. Since the patient's subjective experience contains only disjointed fragments of this pattern, the observer must penetrate psychoanalytically

into the unconscious (or, as we prefer to say, "non-reporting") foundations of the patient's subjective experience . In this light, the depressive spell is a desperate cry for love, precipitated by an actual or imagined loss which the patient feels endangers his emotional (and material) security. In the simplest case the patient has lost his beloved one. The emotional overreaction to this emergency unfolds, unbeknown to the patient himself, as an expiatory process of self-punishment. By blaming and punishing himself for the loss he has suffered, he now wishes to reconcile the mother and to re-instate himself into her loving care. The aim-image of the patient's repentance is the emotional and alimentary security which he, as an infant, enjoyed while clinging to his mother's feeding breast. The patient's mute cry for love is patterned on the hungry infant's loud cry for help. His most conspicuous morbid fears (such as his fear of impoverishment, his hypochondriac concern for his digestive organs) are revivals of the infant's early fear of starvation. The expiatory process is PSYCHODYNAMICS OF DEPRESSION governed by the emergency principle of repair: in the organism the pain of lost pleasure tends to elicit activity aimed at recapturing the lost pleasure. However, the patient's dominant motivation of repentance is complicated by the simultaneous presence of a strong resentment. As far as his guilty fear goes, he is humble and yearns to repent; as far as his coercive rage goes, he is resentful. In the fore phase of the depressive spell the patient tends to vent his resentment on the beloved person ,the one by whom he feels "let down" or deserted. He wants to force this person to love him.* When the patient feels that his coercive rage is defeated, his need for repentance gains the upper hand; his rage then recoils and turns inward against him, increasing by its vehemence the severity of his self-reproaches and self-punishments. As a superlative bid for forgiveness, the patient may thus be drive into suicide. When he attempts to finish his life, he appears to be acting under the strong illusion that this supreme sacrifice will reconcile the mother and secure her nourishing gracesforever. A significant feature must be added to the characterization of the love-hungry patient's coercive rage.

This rage proposes to use the patient's teeth as coercive weapons. The infant's teeth enhanced his alimentary delight; but rage remembers the destructive- power of biting and chewing. In the non-reporting reaches of his mind, the enraged patient is set to devour the frustrating mother herself as a substitute for food. Moreover, her disappearance from the scene will enable the smiling mother to re-appear with her dependable offerings of food .In dire need, prehistoric tribesmen may have devoured their chieftain (later, their totem animal) with similar ideas in mind. Sometimes this "cannibalistic" feature is clearly revealed in the depressed patient's dreams. Fasting, the temporary cessation of biting and chewing, is in turn one of the earliest and most enduring forms of punishment and selfpunishment in our civilization ("tooth for tooth"). It appears in the cultural patterns of expiation and reappears in the depressive version of expiation for the same psychodynamicreasons.* The patient takes pride not in his repentance, but in his coercive rage, even after defeat has retroflexed and forced this rage to sub serve his repentance. Thus he punishes himself not only for his defiance. According to an anecdote, the father of Frederick the Great was overheard shouting as he beat one o the lackeys, "You must love me, you rascal." Another version of morbid fasting is known to the medical profession as "anorexia nervosa" but also, in continued defiance, for his inexcusable failure to terrorize the beloved one (the mother) in the first place. Furthermore, the retro flexion of rage is never complete; the expiatory process is continuously complicated by a residue of straight rage which remains directed against the environment. T he merciless, though unconscious, irony with which the patient blames even the failings of the beloved one on himself demonstrates spectacularly this residue of straight rage. By reducing his self-reproaches to absurdity, he succeeds in venting his resentment on the beloved one at the height of his forced contrition and self-disparagement. The extreme painfulness of depression may in part be explained by the fact that in his dependent craving the patient is torn between coercive rage and submissive fear, and thus

strives to achieve his imaginary purpose, that of regaining the mother's love, by employing two conflicting methods at the same time. The struggle between fear and rage underlies the clinical distinction between retarded depression and agitated depression. If rage is sufficiently retroflexed by the prevailing guilty fear, the patient is retarded; if the prevailing guilty fear is shot through with straight environment-directed rage, he is agitated. Whenever antagonistic tensions of equal or nearly equal strength compete for immediate discharge, they tend to produce an interference pattern of discharge. We call this psychodynamic mechanism discharge-interference. His retarded behaviour, on the other hand, is explained as an inhibitory effect of the combined action of guilty fear and pain. Based on these findings, we view depression as a process of miscarried repair. To a healthy persona serious loss is a challenge. He meets the emergency by calming his emotions, marshalling his remaining resources, and increasing his adaptive efficiency. Depressive repair miscarries because it results in the exact opposite. Anachronistically, this repair presses the obsolete adaptive pattern of alimentary maternal dependence into service and by this regressive move it incapacitates the patient still more. Historically, this theory developed as follows. Retroflexed rage is one of Freud's early clinical discoveries; he described it as "sadism (aggression) turned against the self." In 1917, Freud suggested that the depressed patient's ego metamorphoses into a replica of the lost loveobject. This replacement by identification, Freud continued, serves the patient's ambivalence, his hate as well as his love, for at the same time he turns his sadism MULTI-PERSONALITY DISORDER The psychodynamic explanation in Freudian psychodynamics refers to a theory of human behaviour. Simply put, we are the product of interplay between the three elements of the "psychic apparatus". These elements are the id, ego, and superego. The id consists of instincts and basic drives including our sexual drive. The ego in a way is similar to the

CEO of a company in that it is in charge of executive and intellectual functions. Furthermore, the superego is the centre of morals and ideals. These elements do not always work in harmony. Their conflicts can lead to a simple change in behaviour and personality traits, or can be as serious as a mental illness that requires psychiatric attention. It is of note that not all three elements reside in the conscious part of our psyche. The id for instance is entirely unconscious. The superego is mostly unconscious while the ego processes reside mostly in the conscious realm. SUICIDE Knowledge of the psychodynamics of suicide helps to distinguish which patients with any given diagnosis are most at risk for suicide. Such knowledge is essential for the evaluation and treatment of the suicidal patient. The psychodynamic meanings of suicide for a patient derive from both affective and cognitive components. Rage, hopelessness, despair, and guilt are important affective states in which patients commit suicide. The meanings of suicide can be usefully organized around the conscious (cognitive) and unconscious meanings given to death by the suicidal patient: death as reunion, death as rebirth, death as retaliatory abandonment, death as revenge, and death as self-punishment or atonement. It also include: the role of anxiety in suicide; the capacity to bear hopelessness, rage and other unpleasant affects without regression; the use of particular defense mechanisms in distinguishing the risk for either suicide or violent behaviour; and the relation of specific psychodynamic conflicts seen in suicide to particular psychiatric diagnoses. Higher levels of suicidal intent were associated with less differentiated self and object representations and less emotional investment in relationships. More severe depressive symptoms in suicide attempters were correlated with more self-targeted anger; less eternally directed anger, higher levels of shame and guilt, more affectively negative views

of relationships, greater use of maladaptive and self-sacrificing defenses, and more impaired reality testing. PTSD Psychodynamic approaches to PTSD focus on a number of different factors that may influence or cause PTSD symptoms, such as early childhood experiences (particularly our level of attachment to our parents), current relationships and the things people do (often without being aware of it) to protect themselves from upsetting thoughts and feelings that are the result of experiencing a traumatic event (these "things" are called "defense mechanisms"). Unlike cognitive-behavioural therapy, psychodynamic psychotherapy places a large emphasis on the unconscious mind, where upsetting feelings, urges and thoughts that are too painful for us to directly look at are housed. Even though these painful feelings, urges and thoughts are outside of our awareness, they still influence our behaviour. Psychodynamic psychotherapy for PTSD has not been studied as extensively as cognitive-behavioural therapy for PTSD. Of the studies that have been conducted, though, it has been shown that psychodynamic psychotherapy can have a number of benefits. For example, studies of psychodynamic psychotherapy for PTSD have shown that after therapy, people report improvement in their interpersonal relationships, fewer feelings of hostility and inadequacy, more confidence and assertiveness and reductions in PTSD symptoms and depression. Both cognitive-behavioural therapy and psychodynamic psychotherapy can have benefits for someone with PTSD. Cognitivebehavioural and psychodynamic therapists, however, take different approaches to the treatment of PTSD, and some people may prefer one approach to the other. VII. Interventions, Management and Treatment

NURSING INTERVENTIONS (PTSD) 1. Encourage adaptive coping strategies and techniques to help patient verbalize fears and worries. 2. Help the patient the connection between trauma and current feelings, behaviors and problems. 3. The nurse should be non-judgmental, honest empathic and supportive in order to gain the trust and establish rapport. 4. Evaluate past behaviors in the context of the trauma not in the context of the current values and standards. 5. Help the patient to develop interpersonal skills and reestablish relationships that provides support and assistance. 6. Help the patient ventilate feelings of anger in order to lessen stress and anxiety levels. 7. Offer and provide a safe environment to the patient because of suicidal tendencies he is having. 8. Patient needs to be involved in problem solving, decision making, and taking specific actions towards overcoming stresses. NURSING INTERVENTIONS (MULTI-PERSONALITY D/O) 1. Take an objective, matter-of-fact approach to patient care. 2. Keep verbal and non-verbal messages clear and consistent because patients may have suspicions towards the nurse and the environment. 3. Provide a daily schedule of activities in order for the patient to know and familiarize routines so that levels of anxiety are reduced. 4. Maintain focus on reality-based, low stress topics. 5. Gradually identify feelings implied or expressed by the patient. 6. Set limits on manipulation and disregard for rights to others. 7. Encourage the patient to verbalize feelings of anger, rejection, fear and inferiority to lessen anxiety levels and to know the background behind these.

8. Avoid argument and debate; use humor and gentle feedback because patients may have the tendency to harm others if they are provoked with certain factors. 9. Explore the patients feelings; examine constructive means of expressing anger. 10. Use problem-solving approaches to help the patient explore changes. 11. Facilitate successful experiences with task completion and goal achievement. NURSING INTERVENTIONS (DEPRESSION) 1. Encourage the patient to discuss looses or changes in life situations. 2. Encourage the patient to express sadness or anger and allow adequate time for verbal responses. 3. Encourage the use of problem solving and positive thinking. 4. Spend short periods of time with the patient all throughout the day to establish relationship and help the patient know that someone is willing to listen with him. 5. Assess for suicidal clues and intervene to provide safety precautions as necessary. 6. Assist with ADLs if the client is unable to perform them. 7. Provide activities to increase self-esteem and help in alleviating guilt feelings. 8. Ensure good nutrition by providing high calorie, high protein snacks. 9. Encourage adequate sleep and rest periods. 10. Decrease environmental stimuli to lessen provoking factors that may precipitate stress. NURSING INTERVENTIONS (BIPOLAR D/O) 1. Remove hazardous objects in the environment to avoid harm to self and others. 2. Reduce environmental stimuli that may predispose to feelings of anxiety or mania.

3. Assess the client closely for fatigue and use comfort measures to provide adequate rest and sleep periods. 4. Encourage the patient to ventilate feelings to verbalize anger, fear or rejections that may predispose to mania and depressive episodes. 5. Ignore and distract the client from grandiose thinking by resenting reality in a non-judgmental and non-arguing manner. 6. Limit group activities that are competitive to avoid provoking situations that may induce mania or anxiety to patient and assess the tolerance level. 7. Provide simple and one on one structured activities with the nurse. 8. Provide simple and direct explanation for routine procedure to facilitate cooperation and decrease levels of incoherence and unfamiliarity. 9. Set limits on inappropriate behavior; be firm and consistent in doing so. 10. Provide physical activities and outlets for tension. VIII. Reaction and Significance to Nursing Practice Sybil is an astonishing and spellbinding movie which makes you to think and look at yourself and the other people around you in a new way. It's the story of a survivor of terrifying childhood abuse, victim of sudden and mystifying blackouts, and the first case of multiple personality ever to be psychoanalyzed. The movie was set at the 20th century New York. The theme and motifs of the movie was based on this era where the characters can be seen wearing vintage clothing including tight fitting but bottom flared pants for the males and eyeglasses of antique styles. The background was in perfect harmony to the theme since the year Sybil existed (1923)and the year she seek consultation with a doctor (1954), modern America already existed as it is evident in the movie. The picture is very commendable and pleasant to the

eye because of its clarity and can be described as one of the best among its contemporaries within that time. The main character Sybil was portrayed by Hollywood actress Sally Field. She showed great emotional range as a woman with multiplepersonality disorder. She is very remarkable in that role since emotions and mannerisms were being displayed exactly as it is expected. Her efficiency as a drama actress was very profound in this film because different personalities in which she must elicit was showcased excellently. You can easily differentiate when Sybil has taken on a different personality each time because of the various facial expressions and actions of the actress in accordance to the character of that personality. With the sixteen selves to whom she played, both women and men, each with a different personality, speech pattern, and even personal appearance, you'll experience the strangeness and fascination of one woman's rare affliction. Sally Fields dialogues are very well comprehended and delicately spoken which is comparable to well-educated persons who came from old school. Doctor Cornelia Wilbur, a psychiatric doctor, was portrayed by actress Joanne Woodward. Joanne Woodward was convincing in her role just as well. Aside from her magnificent beauty and smiles, her role fits her very well. She was very therapeutic and attentive to Sybil. Her display of patience and affection including the voice is genuine and it is as if she was not just acting her role. The part in which she admitted to herself through a phone call that she became impatient, too eager and pushed Sybil to her limit.., it was clearly registered on Woodwards face. Martina Bartlett who took on the role of Hattie as Sybils mentally disturbed mother is convincingly cruel. She did not have to exert too much effort since her burly built physique and face alone are already terrifying much like to a child. With only four to five part exposure to the movie, her paranoid, schizophrenic character has already made an impact to the movie as a whole. Other cast has done their job as actors just fine. The production elements that worked to tell the story were very effective. The screen writing,

the script, the cinematography and the acting has worked well in harmony. And yet, the film was unpredictable and takes you by surprise. As a whole, the movie was a moving human narrative. It has met beyond our expectations as movie viewers. It is the not kind of drama that will move to you to shed fountain of tears but it is a kind that makes you realize and ponder upon the effects of abuse most especially to a child. It is a common knowledge that the most crucial stage of development is the childhood. For that reason, any memories created at that stage was the most long lived. If parents showered their children with affection and happiness, happy memories will also remain and makes a sunny disposition to the child, whereas parents who abused their child brought bitterness, hatred, incapacitating fear, low self-esteem, inability to show affection and anger to them. This was what happened to Sybil. In the movie, Sybil Dorsett had experienced a traumatic and very stressful situation inflicted by her own mother. In here, we are able to acknowledge the significant role of a family in the development of a childs personality. Personality development is fostered inside the family and initially concentrated in the mother child interaction. Healthy interactions between the child and the mother will facilitate the child to develop into an adult family member who is able to protect the self. When the mother responds calmly and reciprocally to an anxiety provoking situation, attachment behaviour is facilitated. But since Sybil had experienced the opposite, multiple personality disorder or dissociative disorder had evolved. She dissociated herself to survive and escape child abuse and it gave her temporary relief and cope with trauma. In relevance to the nursing practice, the case of Sybil is interesting, considering the complex and fascinating nature of the multiple personality disorder or the dissociative disorder as it exists today. In psychology, it is a known fact that Multiple Personality Disorder (MPD) is associated with child abuse. The personality "splits" when the human psyche can no longer cope with the pain of abuse.

Since the evolution of psychiatric nursing in the 19th century that marked the beginning of humane treatment wherein an environment of understanding and sense of contentment in mental and physical health have been emphasized, the unique contributions of psychiatric nurse in caring for the mentally ill have been developed. Nurses rather than physicians play a greater role in caring and promoting health. With the growing populations of persons with diverse mental health problems, a nurse requires astute observational and clinical skills to understand what the client experiences. Same thing is true for the novice student. Concepts in psychiatric nursing are a critical element in nursing education but it will not complete the whole process with only the theories in the minds of the students. By actual experience or being able to witness a real scenario of a person undergoing severe mental illness, we will be one step ahead in synthesizing biological, spiritual, and psychosocial concepts. The movie Sybil will help students integrate concepts of holistic nursing, adaptation and the response of the patient. This will provide the students better understanding and insight in the adaptive and maladaptive responses of the main character to her stressors and their impact in her mental health. The movie will help the student assess signs and symptoms and incorporate nursing interventions that will modulate the overwhelming impact of stressful situations, thus preventing their negative sequel.