Psych CASC / OSCE · Professional — psychological therapies
Explain psychodynamic vs supportive therapy and negotiate a therapy frame — CASC communication station
MRCPsych/FRANZCP-style CASC: plain-language explanation of modalities, collaborative contracting, boundary holding without humiliation, and safety-netting.
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Target exams
Station brief
Format. Communication station, approximately 7–10 minutes active time after reading. You are the psychiatry registrar in outpatient clinic. [1]
Candidate instructions. Explain psychodynamic and supportive psychotherapy in accessible language. Agree what approach fits now. Negotiate a clear therapy frame (time, contact rules, goals, risk). When the patient idealises you and requests after-hours personal contact, hold the boundary with warmth, explore meaning, and reaffirm ongoing care. Do not lecture, flirt, or abandon. Do not invent statute numbers. [2][4]
Candidate scenario
Your patient is 34, three months after a depressive episode, still low in confidence, describing repeated relationships in which they feel abandoned. They say: "I want deep therapy that looks at my childhood — not just tips. You are the first doctor who really gets me. Can I text you at night when I panic? Maybe we could meet for a walk sometimes so it feels more real." Mood is improved enough for outpatient work; no active suicidal plan today, but they have self-harmed by cutting in the past when rejected. [1][4]
Marking domains
- Warm, collaborative, non-jargon explanation of both modalities and continuum
- Individualised recommendation (blend/support first vs more exploratory) with rationale
- Clear frame: session times, after-hours crisis pathway vs personal texting, goals, review
- Idealisation acknowledged without collusion or humiliation
- Boundary held on dual-relationship/personal social contact
- Risk acknowledged (past self-harm when rejected); safety-netting
- Invitation of questions; shared plan; professional stance throughout [2][3][4]
Reveal assessor key
Open. Thank them for saying what they hope for. Summarise: depression recovery, relationship pattern of abandonment fear, request for deeper understanding and more contact. [1]
Explain modalities simply. "One approach looks more at repeating patterns in relationships and feelings that sit outside full awareness — psychodynamic work. Another focuses more on strengthening coping day to day, solving current problems, and building on what works — supportive therapy. In real care we often blend them depending on how stable things feel." Mention evidence exists for talking therapies of these kinds without dumping trial names on the patient. [1][2][3]
Recommend. For now: structured sessions with both supportive skills and gradual pattern work if they want insight; review after a set number of sessions. Keep medication/review of depression as needed. [3]
Frame. Agree weekly (or service-appropriate) time-limited contract; goals (mood, relationship patterns, self-harm alternatives); crisis pathway (service number/ED) rather than personal night texts; no social walks or dual friendships — explain that the professional frame keeps therapy safe when strong feelings arise. [4]
Idealisation and contact pressure. Name that feeling "you are the only one" is important clinical material linked to abandonment fears; it is welcome to talk about in session. Decline personal texting/social meetings kindly; offer that panic skills and a crisis plan will be built in-session. Check whether the limit feels like rejection; repair alliance. [4][5]
Risk. Acknowledge past cutting when rejected; collaborate on warning signs and alternatives; document; escalate if risk rises. [4]
Close. Summarise plan, next appointment, what to do if distressed after hours, invite questions. [2][4]
References
- [1]Shedler J The efficacy of psychodynamic psychotherapy Am Psychol, 2010.PMID 20141265
- [2]Winston A, Pinsker H, McCullough L A review of supportive psychotherapy Hosp Community Psychiatry, 1986.PMID 3781499
- [3]Markowitz JC Supportive Evidence: Brief Supportive Psychotherapy as Active Control and Clinical Intervention Am J Psychother, 2022.PMID 35232221
- [4]Gutheil TG, Gabbard GO The concept of boundaries in clinical practice: theoretical and risk-management dimensions Am J Psychiatry, 1993.PMID 8422069
- [5]Gabbard GO A contemporary psychoanalytic model of countertransference J Clin Psychol, 2001.PMID 11449380