Treating individuals with multiple problems: On roads not taken

Comments on the article by S. Ziv-Beiman (see record 2015-39481-001), which discusses the dilemmas around the treatment of Dana, a patient with resistant trichotillomania. To the author's mind, integrative treatment is built on three main propositions. The first is of goal setting: clearly defining the goals which are tightly related to the case formulation. A second proposition is that of collaboration between the patient and the therapist. A third proposition is the reliance on empirically available evidence. How do these general principles relate to the clinical dilemma in the case of Dana? The main clinical dilemma is this case was when do we accept the patient's unwillingness to focus on what seems to be a serious and debilitating problem (problem A) and focus on other problems (B, C, or D) instead? The solution to this dilemma in the case of Dana relates to two central issues: first, the consistent exploration of Dana's future, life plans, and fantasies. Second, rethinking “symptoms” as psychic pain. The comment concludes by discussing trichotillomania distress, shame,. and interpersonal relationships