Altruism and Boundary Violation

ABSTRACT

The desire to help others is a common motivation for becoming a therapist, and boundary crossings are an expectable part of psychotherapeutic work. However, progression to boundary violation is rare. The concept of an altruistic boundary violation is presented and illustrated with detailed clinical material drawn from the analysis of Mrs. A,¹ a generally ethical therapist, whose violation of the therapist/patient boundary with her patient, M, began as an altruistically motivated enactment and boundary crossing. In Mrs. A’s case, and arguably in all similar altruistic boundary violations, a specific fit existed between patient and therapist. The intense need to rescue this particular patient was fueled by Mrs. A’s history of early physical and abandonment trauma, which increased her vulnerability to overidentification with her traumatized patient. The stress of relocation to another city and closing her practice further magnified her susceptibility. The complex clinical, professional, ethical, and legal issues inherent in consulting on such a case are discussed. I describe my countertransference and my parallel enactment, an initial crossing of the boundary between the roles of supervisor and therapist.     

Using parent-infant dyads as models for interpreting the parallel process

Studies indicate that parents replicate with the therapist the behaviors and perceptions they experience with their infants. During parent-infant therapy, the therapist may validate perceptions by comparing the parent's behaviors with verbal disclosures. A similar phenomenon occurs in psychotherapeutic supervision. Therapists in training tend to replicate with the supervisor the interactions of their patients, a phenomenon labeled parallel process.This paper suggests that parent-infant interaction may provide insight into the therapistpatient and therapist-supervisor relationships. Understanding the parallel process that occurs during parent-infant therapy may help the therapist explore the patient's perceptions and resolve conflict.     

Inhabiting Mutuality—The Mutuality of Vulnerable States in Psychotherapy: A Discussion of “Did You Say He Has a Hitler Mustache?: Analytic Vulnerability and Destabilization in the Face of Trauma”

This discussion of Sandy Silverman’s clinical vignette explores the realm of mutual vulnerability in working in realms of trauma and dissociation, where internal bad objects threaten the physical and emotional stability of patient and therapist alike. I consider some ways in which therapist and patient alike can be helpful to one another when unbidden thoughts parachute in to the field of therapy, even as they resist being “seen” for what they are.     

Resilience Among Urban African American Male Adolescents: A Study of the Protective Effects of Sociopolitical Control on Their Mental Health

Resilience refers to the notion that some people succeed in the face of adversity. In a risk-protective model of resilience, a protective factor interacts with a risk factor to mitigate the occurrence of a negative outcome. This study tested longitudinally the protective effects of sociopolitical control on the link between helplessness and mental health. The study included 172 urban, male, African American adolescents, who were interviewed twice, 6 months apart. Sociopolitical control was defined as the beliefs about one's capabilities and efficacy in social and political systems. Two mental health outcomes were examined—psychological symptoms and self-esteem. Regression analyses to predict psychological symptoms and self-esteem over time were conducted. High levels of sociopolitical control were found to limit the negative consequences of helplessness on mental health. The results suggest that sociopolitical control may help to protect youths from the negative consequences of feelings of helplessness. Implications for prevention strategies are discussed.     

Rebirth fantasy and the psychoanalytic process

In this paper, Jungian and Freudian perspectives on the fantasy of rebirth are explored and a brief review of the literature on the theme is used to show how that the rebirth fantasy seems to be a universal fantasy in the human mind, connected with the experience of both destruction and creation. In the psychoanalytic process the rebirth fantasy is connected with initial hopes for a better life, but is also a vehicle for creating the analytic pair and for separating from the 'totalitarian object'. An account of clinical work with a patient is given to illustrate the mutual and parallel process of rebirth in both the patient and the therapist. For the patient, the therapy was experienced as an awakening or a birth. The therapist was initially doubtful about the patient's capacity to engage in the analytic process but his involvement and interest were 'born' during the early sessions, enabling the patient to rely on him to lead her out of the claustrophobic power of the totalitarian object.     

The dynamics of empirically derived factors in the therapeutic relationship

The therapeutic relationship is the source of major concepts in psychoanalytic clinical theory. Such concepts as resistance, transference, countertransference, and the alliance are fundamental, even though there may be shifts in meaning between theoretical schools and clinical contexts. In the clinical psychoanalytic literature, disagreement exists over the nature of the alliance and its essential components. Empirical studies using reliable patient, therapist, and observer scales to assess the alliance demonstrate a correlation with psychotherapeutic gains. In the study reported here, thirteen patients were followed for 6 to 33 months of psychodynamic psychotherapy, during which time their views of the therapeutic relationship were assessed, and several experiential measures taken, all on a weekly basis. Statistical analyses reveal that the therapeutic relationship, as reflected in the patients' weekly responses to the St. Louis Therapeutic Relationship Rating Scale, has four distinct components: therapeutic alliance, resistance, transference love, and negative transference. On a week-by-week basis, the therapeutic alliance was the strongest predictor of improvement in patient-reported general adjustment, as reflected in such areas as self-esteem, positive affect, social relations, work productivity, satisfaction, and optimism. Time plots of the variables show the typical time course for the components of the therapeutic relationship, as well as for improvement on the experiential variables. Results indicate that the therapeutic alliance, transference, and resistance are central components of the psychotherapeutic relationship, which in turn predict the ongoing life experience of the patient.     

Stained Hands: Commentary on Paper by Gillian Straker

I attempt, in this discussion, to deconstruct the jouissance present in the witnessing of a deliberate annihilation of a human being. I propose that the crisis in the analyst's subjectivity is linked to an unconscious identification with that which is most abhorrent and unacceptable. The unknowability of trauma ensures that its presence will be enacted in a complex system of mutual influence between analyst and patient in which the roles of victim, perpetrator and bystander oscillate between and within the participants. Taking the discussion to the broader sociopolitical level, I make an analogy between the destructiveness of the South African regime under apartheid and the current destructiveness of the U.S. engaging in a pre-emptive war. In a similar way to how Straker may feel contaminated by her patient's complicity in annihilation, so too are we contaminated by the atrocities perpetuated in the name of our country, even if they are policies we condemn.     

Fear and Shame in an Israeli Psychoanalyst and His Patient: Lessons Learned in Times of War

Living in the midst of a war presents unique challenges to ongoing psychotherapeutic treatment. This paper focuses on the ever-present threat of fracture to the analytic frame and the limited ability of the therapist to create a safe, insulated environment— a reliable container—in which to work, while coping with a violent external reality. Using an intrapsychic lens, as well as an interpersonal one, the dynamics of both the analyst's and the patient's fear and shame are brought into focus. This delicate balance is illustrated through two cases: one occurring during the First Gulf War (1991) and the second taking place during the Second Lebanon War (2006). In both cases, fear and shame cause a stalemate in the psychotherapeutic process. The analyst recalls his active duty as a soldier during the Yom Kippur War (1973). These memories and their attendant acknowledgement of fear and shame by the analyst, as well as his analysand's “supervisory” comments, gradually dissolve the knot and repair the rupture in the analytic process. The ability to fully experience fear, shame, and helplessness is at the core of psychic health, a health once destroyed by dissociation and denial of these feelings. This ability to experience fear and shame is the psyche's antidote to mental breakdown. Following discussion of the two case studies, this paper seeks to illustrate how the very structure of a society, in this case Israel, can codify societal defense mechanisms against emotions like fear and shame, exacerbating the very problems it seeks to assuage.     

The value of problem-case discussions for long-term care using the example of psychogenic gait disorders in children

The psychotherapeutic treatment of two patients with hysterical disorder of walk showed the importance of problematical cases seminars for deranged therapist/patient relationship. The seminars effected on the collaborators attitude of the psychotherapeutic ward to the patients. The therapists were so emotional confined by faulty assurance of the diagnostic classification and by non-realistic expectations of rapid results, that the therapeutical treatment began to stop.     

Problem-oriented sessions: Presentation of a method for therapeutic work within a narrow time frame

Abstract

A method of problem-orientation has been developed as a delimited psychotherapeutic procedure comprising four sessions with a psychotherapist. The distinguishing feature of this method is the distinct time frame, within which the therapist grasps the patient's current situation and difficulties. The sessions are disengaged from considerations about the need for further treatment. The therapist appeals to die reflective part of the patient and attempts to awaken their curiosity about themselves in order to explore inner associations concerning core problems. The four problem-oriented sessions are offered during the initial telephone contact to the person who wishes to gain a greater understanding of their own part in their difficulties and who is able, already in the introductory telephone conversation, to embark upon an exploratory dialogue about these problems. The sessions are strongly characterized by this short-term perspective; the intensity increases and attention is sharpened. The stance adopted by the therapist during die sessions is one of balancing a non-appraising, empathic and confirmatory listening aimed at making connections with reality and a faith in the patient's resources and capacity to maintain a sense of responsibility for their life; an approach which limits the patient's tendency to regress. Transference is not interpreted explicitly but is used by the therapist to understand the patient. Supervision is an important and essential component, whereby the therapist receives help in increasing understanding of that which is played out during the sessions and also of their own counter-transference. This understanding constitutes the foundation of the therapist's tentative formulations of that which is central in the patient's problems.     

Adolescents' views on war and peace in the early phases of the Iraq conflict

Adolescents' views of war and peace were assessed among 209 children aged 10-14 who attended a parochial school or its after-school religious program located in a predominantly middle-class, suburban area within commuting distance of New York City. Findings were compared to those of youth surveyed during other armed conflicts, specifically the Vietnam War, the first Persian Gulf War, and the U.S. military involvement in Latin America. The study took place in early fall 2003, and results were interpreted in light of the social climate and complex realities of post 9/11 in New York State, the Catholic Church's initial opposition to the Iraq conflict, and popular opinion. In spite of differences between the Iraq War and other conflicts, findings are remarkably similar. Although the present group is highly preoccupied with terrorism and nuclear war, even in a time of war, participants show concern for what they perceived as affecting their lives directly, rather than with conventional war. While they believe that President Bush was honest about the war in Iraq and right in sending troops, they do not glorify war. On a theoretical level, they overwhelmingly believe that wars are bad and the majority is optimistic that world peace is possible, though they realize that wars are difficult to prevent, believe that they are sometimes needed, and will occur in the future. Unlike the Catholic group surveyed by Tolley during the Vietnam War, however, participants are not as ready to die for their country, although findings show that, overall, like past groups, more boys tend to be pro-war than are girls and participants' views tend to reflect contemporary public opinions.     

Lost in translation,found in translation: A case study of working psychodynamically in an interpreter-assisted setting

Effective use of psychotherapeutic treatment in interpreter-assisted settings is well established; however, there has been little discussion of the use of psychodynamically informed treatments in such settings. The literature suggests that therapy facilitated by interpreters is not conducive to psychodynamic approaches due to the presence of a third person, the perceived lack of intimacy, and the difficulties of working with translated material. However, transference, countertransference and other unconscious communications and responses necessarily occur in every therapeutic setting, including triadic therapy using interpreters. This article describes a short-term (12 session) psychodynamically oriented intervention with a 52-year-old Cantonese-speaking man suffering from depression. A female, Chinese-born interpreter assisted in every session. The integral role of supervision in supporting a containing relationship between the therapist and the patient and the difficult emotional responses experienced by the interpreter is highlighted. The article attempts to trace some of the unconscious communications that occurred during the therapy and demonstrates the feasibility of working psychodynamically in an interpreter-assisted setting.     

BONE MARROW TRANSPLANTATION IN A PATIENT WHO EXPERIENCED TORTURE IN A PRISONER OF WAR CAMP: NARCISSISM AND SURVIVAL

Post-traumatic stress disorder has been described as a syndrome from which an individual may suffer as a result of extraordinary trauma. Torture of prisoners of war in Serbian camps during the war in Croatia is just such a stressful situation that requires mobilization of all defense mechanisms of an individual. The authors present a case study of a former prisoner of war who acquired acute myelogenous leukemia several months after release and was treated with bone marrow transplantation. On release the patient was medically examined, like all prisoners of war, and the findings did not suggest any disease. Because of the situation, the patient was in psychotherapeutic observation and treatment after his illness was diagnosed and throughout the transplantation treatment.     

Paradox as Epistemological Jump

Recent articles on paradoxical interventions tend to view them as something given by a therapist to a patient, thus unintentionally adopting a unidirectional view of causality and an outmoded epistemology. It is postulated that change takes place in the context of a patient-therapist relationship and that when that relationship becomes paradoxical it becomes more difficult for the patient to view himself as a reified "thing." Paradox effects change, then, by altering the meaning of experience and modifying epistemological assumptions.     

“Operationalism” in psychotherapy: A possible means of putting a sorry state of theory in better order?

It will be shown in this paper that the study of the actual conduct of psychotherapy, at least in its classical form with a patient speaking his or her mind in any way the patient desires and a therapist helping the patient pursue those thoughts and wishes and conflicts and hopes for better luck in real life than before, is more conducive to agreement among rather different therapists, to clearer reasoning over psychotherapeutic interventions, and to more promising theoretical articulations than anything available in the theoretical texts of psychotherapy.     

The rhetorical organisation of dream‐telling

An appreciation of the ways in which clients and patients tell stories in psychotherapy is essential to an understanding of the therapeutic process. This paper reports findings arising from a programme of research into the analysis of patient narratives in psychotherapy sessions and diagnostic interviews. The focus of the current paper is on the analysis of the use of language in patient‐therapist interaction during the recounting in therapy of dream narratives. Dream‐telling follows certain rules of presentation that can be described as a set of specific rhetorical practices. The rhetoric of the dream‐teller reporting a dream is one of emotional distance, reflecting a narrative sequence which lacks a motivational framework. The report needs to be put into context by establishing a dialogue with the listener. The sharing of the dream with another, especially in the psychotherapeutic context, represents the dream‐teller's attempt to reproduce the dream experience. This attempt is made with reference to a responding and commenting other. The function — or dysfunction — of the assumption of hidden, non‐obvious, non‐recognisable wish‐fulfillment scenarios in patients' dreams is discussed. A method of working with dream material derived from narrative research is briefly described: the dramaturgical approach. This approach emphasises collaborative negotiation between client/patient and therapist, and combines the idea of free association with dream reconstruction and embedding the dream in current concerns, desires, and challenges.     

Stochastic analysis of the duration of the speaker role in psychotherapy

An analysis has been undertaken of the stochastic behavior of the time series which defines the duration of utterances exchanged by patients and therapists in six recorded sessions of psychotherapy. Each series followed a Box-Jenkins time series model of order (1, 0, 0): that is, each behaved as a first-order autoregressive process, sensitive to the prior state of the system. The confidences associated with the parameters of the autoregressive models were very high. In addition, the histograms of length of each utterance indicated an underlying Poisson model for the emergence of speech. The parameters of the Poisson and autoregressive models varied with each patient/therapist pair. Signatures for the process dynamics of the speaker-role variable were obtained. The two analyses suggest fundamental structures within the psychotherapeutic dialogue. The Box-Jenkins results provide a global summary of the inner structure of the series and its progression, while the Poisson results describe its instantaneous behavior. This work is offered as a part of new efforts to apply scientific and mathematical methods to the psychotherapeutic domain.     

Deliberate self-harm and sexual abuse in adolescence

Helping a young person to render repeated self-injury redundant as a solution to problems connected with having been sexually abused requires a containing context which both supports autonomic healing in the patient and provides an experiential model for the restoration of relationship with adults as a safe (non-abusive) activity. In this paper a case study is presented and some treatment issues for individual psychotherapeutic work are addressed. These include ensuring that the power balance between patient and therapist is acknowledged by emphasizing the patient's self-determination, recognizing patterns of re-enactment within sessions, and addressing here-and-now behaviour and its link with the original trauma. This paper also examines the changing function of self-injurious behaviour and how it can be perceived as addictive after the establishment of a proper alliance between patient and therapist. the circular logic involved in avoiding identification with the abuse-perpetrator by way of self-injury is explored. the therapeutic relationship as an alternative to this is discussed.     

The trial period and the creation of analytic patients

Just as there are many roads to Rome, the trial period may be considered one of many opening moves in psychotherapy or psychoanalysis. The responsive – and responsible – therapist must be many things to many patients, some of whom know nothing about the psychotherapeutic/analytic process. Freud advocated the trial period to help him take a “sounding” when he knew little about the patient and when the patient knew little about psychoanalysis. R.I.P.? This brief communication laments the apparent demise of this promising procedure and makes an effort at resurrection by describing the hitherto unmapped latent structure of the trial period. Even if there are fewer patients in psychoanalysis today, there may be a number of reasons to recommend a trial period, no matter what we name this period of optimistic uncertainty at the beginning of every treatment. Even if “consultation” is the term de jour, the psychoanalytic psychotherapist cannot escape certain role responsibilities at the beginning of every treatment, which has been made clear in the ethical principles of the American Psychoanalytic Association. What we will learn about the trial period should serve our understanding of what must also occur in the beginning of every psychotherapy or psychoanalysis. Conceptually, I propose that a trial analysis (1) will serve as a discriminative stimulus, signaling, to the patient, the unique nature of the analytic conversation; (2) will permit an in vivo assessment of the patient's suitability for psychoanalysis, and, more importantly, the fit between analyst and patient; (3) will provide anticipatory socialization for the unfamiliar and difficult roles of patient and therapist within the analytic process; (4) will offer true informed consent about the task facing therapist and patient; and (5) will facilitate an opportunity for therapeutic assessment, all of which will help the naive patient acquire the skills and lived experience to become an analytic patient. The trial period is the perfect host for all that must happen – and what we can do– to help naive patients become analytic patients.