Engagement and the Therapeutic Relationship in Systemic Therapy

This paper is about the therapeutic relationship in systemic therapy and, more specifically, about engagement as a process. Beginning with some practice examples, a critique is made of the way in which both the therapeutic relationship and engagement have been under-theorized in systemic therapy. Two different sets of ideas are used to develop some thinking about the process of engagement: the notion of the 'good-enough' engagement as the environment or frame of therapy is developed, and the systemic concept of sequences is held alongside the psychoanalytic ideas of transference, countertransference and projective identification. This theory discussion is used to reflect on the original practice examples.     

Pete the diesel: Psychotherapy with a severely disturbed five-year-old boy

The psychic significance of the figure of the grandmother in psychodynamic psychotherapy has received scant attention. This paper develops the concept of the ‘grandmaternal transference’ in parent–infant psychotherapy and explores its identification, its possible functions and its therapeutic significance. The grandmaternal transference has special relevance to parent–infant psychotherapy since the grandmother often represents both the mother’s mother and the child’s grandmother and offers a unique third position between mother and child. Three clinical vignettes illustrate how the grandmaternal transference may operate in this third position. In the first vignette, the therapist becomes in the transference a containing grandmother thereby facilitating maternal containment. In the second case, the therapist may be experienced as a differentiating grandmother able to help mother and infant with separation and individuation. In the third one, the therapist is transferentially experienced as a paternal grandmother who acts as a pseudo-father able to embody the paternal function. In each of these positions, the transference and countertransference – whether positive or negative – require that the therapist responds to rather than enacts the grandmaternal role. The three configurations of the grandmaternal transference have different clinical manifestations and offer different therapeutic ports of entry.     

Systemic family therapy can be manualized: research process and findings

Determining the efficacy of therapeutic interventions is becoming an increasing political and ethical necessity. Comparative therapeutic outcome trials are most powerful when there is a precise specification, or manualization, of the forms that therapies took. Manuals have begun to be developed for structural/behavioural family therapy and couple therapy. The development of these manuals is often reliant on experts' self-report, rather than a systematic analysis of the therapeutic process as it happens. This can limit their validity and applicability to standard clinical practice. In addition, no manuals exist which reflect less structured forms of family therapy aimed at incorporating systemic, postmodern and narrative frameworks. The feasibility of producing a workable manual that reflects the fluidity of such practices has been questioned.
A research project to systematically create and test such a manual is reported. Multiple data sources and research methods, primarily qualitative, were applied to generate a rich specification of the therapy. In reporting these results the contents of various aspects of the final manual are indicated. Procedures to ensure that the prescribed practice is consistent with a widely used approach to systemic family therapy are also described.
The manual will be an important tool for outcome research and therapeutic practice. The account of the research process should be helpful to researchers engaged in constructing a manual for other models of family therapy based on a rigorous analysis of actual practice. The manual itself is available for use by outcome researchers who wish to evaluate this widely used form of systemic family therapy.     

Intimate boundaries: Therapists’ perception and experience of erotic transference within the therapeutic relationship

Aim: This study explored therapists’ understanding and experiences of erotic transference within therapeutic relationships. Method: A small‐scale qualitative research project was undertaken with six therapists working within different counselling contexts. Data was collected through semi‐structured face‐to‐face interviews, and an Interpretative Phenomenological Analysis used for analysis of individual perception and experience. Findings: All participants had experienced what they understood to be erotic transference and/or sexual and loving feelings within therapy. There was little differentiation between the two phenomena, and both were often referred to interchangeably. There were contradictory views as to whether using the phenomena would be beneficial to client work, but there was a strong motivation to learn more about it. Therapists who encountered sexual attraction within therapy experienced feelings including shame and embarrassment. Supervisory support was seen to be beneficial. Implications/conclusion: The importance for therapists to acknowledge a lack of clarity that exists around the understanding of erotic transference and its relationship to sexual attraction within therapy is noted. Also, a recognition that better access to training regarding erotic transference and sexual responsibility within client relationships might be helpful to therapists in their work.     

The many faces of self-harm

This paper explores why open dialogue on the subject of erotic transference and countertransference is so difficult and attempts to offer an understanding of these phenomena which might enable counsellors to work more confidently with it. It also briefly examines the author's own research on therapists' thoughts and experiences of erotic transference, seeking to differentiate between inappropriate sexual contact between clients and therapists and the experience of erotic transference in the context of therapy as a reworking of the Oedipal relationship. Case examples illustrating the experience of countertransference within the therapeutic situation and how its presence can act as a help or a hindrance are offered. The paper concludes by examining the need to reflect on the erotic transference in therapeutic work and proposes its usefulness as a therapeutic tool. Suggestions about how the erotic transference can be managed to therapeutic effect are also explored.     

Eine Therapiestunde mit einem Mörder

Although psychodynamic concepts may be helpful in identifying the complex interpersonal and manipulative processes that occur between inmates and therapists and to transform them into the therapeutic process they are hardly ever applied in a correctional setting. The author provides an insight into the psychotherapeutic work conducted in prison. The first part of the paper outlines the special conditions in which psychodynamic psychotherapy occurs in a social therapeutic intervention institution within the German prison service. Characteristic transference and countertransference constellations are described. Based on a verbatim report an account is provided of a therapy session with a serious violent offender. In his reflections on the session the author focuses on the effects on the transference process of, in the offender’s eyes, being both therapist and assessor at the same time.     

Übertragung und Gegenübertragung in Verhaltenstherapie und Psychoanalyse

Most psychotherapists and researchers agree that a good relationship essentially contributes to therapeutic change. The psychoanalytic concepts transference and countertransference which describe fundamental aspects of the psychotherapeutic relationship have now become integrated into behavior therapy. These concepts, however, are used differently in psychoanalysis as well as in behavior therapy. This makes the communication between psychotherapists coming from different orientations difficult. Therefore, a research approach which describes the important verbal and nonverbal elements of a helpful therapeutic interaction independently from therapeutic orientation could help to evaluate their effectiveness in different psychotherapeutic methods. In this way a culture of integration into psychotherapy could be encouraged.     

Transference, countertransference and mentoring: the ghost in the process

The concepts of transference and countertransference are used in this paper to explore some of the deeper dynamics of the relationship between mentor and mentee; it is hoped that this perspective gives a useful gaze on the mentoring process. Three aspects of the relationship are examined. The first is an exploration of the ambivalent relationship of mentor and mentee to the third party at the meeting--the organisation. The second is an examination of the mentoring process where transference theory illuminates aspects of the power, authority, control, affiliation and resistance in the freezing, unfreezing and refreezing aspects of the ebb and flow of transference and countertransference. The third aspect is an examination of the relationship between mentor and mentee with a glance at the narcissistic impulses of altruism and a sceptical brush with the dominant image of unconditional positive regard that is commonly supposed to flow from mentor to mentee.     

Robert Burns in the counsellor's chair: A socio-cultural analysis of the Burns myth

To illustrate how difficult endings are, this paper first cites an Italian therapist's experience of the use of time with university students in Naples and then associates to contrasting examples in the novel, art, music and the cinema. It uses a dialogue about ending in the film Brief Encounter as a possible paradigm for what is needed in brief therapy. It then refers to the work of James Mann on different experiences of time which underlie the resistance to brief work. How can brief therapy contain the paradox between finite and infinite time? Incorporating another model of therapeutic intervention with the use of Milton Erickson's attitude to time and the unconscious, the paper then moves on to a clinical example, where treatment consisted of an assessment and five sessions. Here the practice of not interpreting the transference is challenged, along with an exploration of the concept of transference to the organization and the use of pre-treatment ‘maternal reverie’ associations. Using the combination of informal trance-like states with a clear focus on the ‘here and now’, the process of the therapeutic relationship is then worked with in the case material.     

An individual approach to psychotherapy with psychotic patients

In this paper I attempt to explore particular aspects of the therapeutic process, especially the unusual way in which the therapy of this 11-year-old girl, referred for possible or potential anorexia nervosa, came to a sudden end. The oedipal configuration provides a useful theoretical framework in which to consider the course and vicissitudes of treatment. The restoration of a link between the child and her father allowed a distance to be created between mother and daughter. The meaning of this is considered both in terms of external events and clinically within the transference relationship.     

Family Therapy Training and Workforce Planning

There is a strong argument for further developing family therapy as a profession within the NHS, using the mechanisms for workforce planning at regional and national levels. Family therapy can be a full-time occupation, as a profession and a secondary activity, as systemic practice. There is ambivalence about professionalism within the field and at different levels of society. This article outlines areas of tension between family therapy and government policies which focus on evidence-based practice. Full integration into the NHS is possible through the career structure which links family therapy with clinical psychology, adult and child psychotherapy, and provides a model for linking workforce planning with education. There are risks of family therapy becoming marginalized in the future, as a profession or as systemic practice, unless it connects better with workforce planning.     

Tanztherapie

Dance therapy is presented as a processorientated psychotherapeutic method. Its historical roots in the German Expressive Dance and in the Human Potential Movement in the USA are discussed together with current trends in Germany. Phenomena as rhythm, the experience of space, vitality contours, nonverbal attunement and movement analysis are discussed theoretically and backed up by short examples of dance therapeutic sessions. The integration of psychoanalysis and dance therapy is illustrated by the approach of Elaine V. Siegel, speaking about physical transference and counter transference. The therapeutic work with body image and the idea of creative movement and playfulness for the purpose of a new orientation of Stern’s RIG`s (representations of interactions that have been generalized) are fit in a modern and psychodynamic oriented concept of dance therapy. Questions concerning indication and current research are shortly summarized. Dance therapy, as the youngest creative therapeutic method beside music therapy and art therapy, is characterized by its openness for interactive scopes, the integration of behavior observation (through movement analysis) and psychodynamic reconstructions.     

The Discursive Performance of Change Process in Systemic and Constructionist Therapies: A Systematic Meta‐Synthesis Review of In‐Session Therapy Discourse

Despite the emphasis of systemic and constructionist approaches on discourse and interaction, to date there has been no comprehensive overview of how change process is performed within in‐session therapeutic dialogue. In this paper, we present a qualitative meta‐synthesis of 35 articles reporting systemic and constructionist therapy process data from naturally occurring therapeutic dialogue. The studies were selected following the screening against eligibility criteria of a total sample of 2,977 studies identified through a systematic search of PsycINFO and MEDLINE databases. Thematic analysis of the 35 studies’ findings identified four main themes depicting change process performance: (a) shifting to a relational perspective, (b) shifting to non‐pathologizing therapeutic dialogue, (c) moving‐forward dialogue, and (d) the dialogic interplay of power. Findings highlight the interactional and discursive matrix within which systemic and constructionist change process occurs. Findings illuminate the value of qualitative research studies sampling naturally occurring therapeutic discourse in bringing this matrix forth, particularly when utilizing discursive methodologies like conversation or discourse analysis.     

The symbolism of the story of Lot and his wife: the function of the 'present relationship' and non-interpretative aspects of the therapeutic relationship in facilitating change

Abstract The treatment of an adolescent patient preoccupied with thoughts about committing suicide is presented, as a vehicle for considering the significance of the 'present relationship' within the totality of the therapeutic relationship in bringing about change. The question of how the present relationship operates alongside the transference relationship is raised. It is argued that there needs to be more attention to and discussion of the therapeutic actions and re-enactments that take place within therapy which, while they may be viewed at times as unorthodox, may nevertheless be beneficial. This in turn can then lead to developments in technical and theoretical thinking based on clinical experience.     

The Development of Systemic Family Therapy for Changing Times in the United Kingdom

In sketching the position of couples and family therapy and systemic practice in the United Kingdom of Great Britain and Northern Ireland (the UK) we have provided what we can of the development of the contexts of training and practice; the content of some of the theories and their applications; and the external realities within which we currently operate. The UK has a well developed structure for training and practice in systemic couples and family therapy. The history is of enthusiastic adoption of therapies from international sources which are generally then incorporated into an overarching systemic framework. Family therapy in the UK is currently subjected to a variety of pressures but is well regulated and is in a strong position to continue making its contribution to the welfare of families.     

Progressive triangulation in psychotherapy and the spiritual journey

Relationship triangles are usually considered symptomatic of family dysfunction in systems-oriented therapy, but they may also serve a progressive, transitional role in relationships. The author examines the phenomenon and function of “progressive” triangles in East and West spiritual traditions, and suggests that triangles comprising seeker, mediator, and higher power are common in both traditions, regardless of differing views of human nature. A progressive triangle in the therapeutic setting can be seen as a function of teleological transference, in which a seeker's spiritual aspirations are projected onto a mediator, who provides support and direction for its further realization. The implications of progressive triangulation and teleological transference in contemporary practice are discussed.     

Five Issues in Training Edited by Irving R. Weschler and Edgar H. Schein

This case study illustrates how combined therapy (individual, group, and marital) by the same therapist was used to resolve a woman's narcissistic transference. The author's position is that combined therapy creates a psychologically stimulating environment, which uniquely elicits a depth and range of transference feelings, thereby generating multiple therapeutic opportunities to experience and work through transference resistance in the here-and-now. Highlights of the treatment demonstrate how the synergy of three modalities is used to elicit, modulate, and resolve positive and negative aspects of the narcissistic transference. Four guidelines are suggested for treatment of patients in combined therapy.     

Systemic therapy and attachment narratives

In this paper we describe how we bring together three major systems of thought: attachment theory; family systems theories; and theories of narrative development, in an integrated approach to systemic practice that we call attachment narrative therapy (ANT). ANT provides a four‐stage framework for practice: creating a secure base; exploring narratives and attachment experiences within a systemic framework; considering alternatives and taking action; and the future and maintenance of the therapeutic base. Formulation, especially regarding the role of emotions and attachments in family dynamics and narratives, is at the heart of our approach and helps us hold ourselves accountable for our particular weave of theory and practice.     

Transference and covenant in pastoral care

Transference raises issues in pastoral care which covenant addresses. Through transference one tames the terrors of life and death. Transference also provides a basis for healing in pastoral relationships. Transference must be managed so that it does not result in idolatry but rather points the helpee beyond attachment to the minister and toward dependence upon God. Covenant provides theological guidance for transcending transference. This covenant involves the pastor-helpee relationship, commitment to God as a third party, and accountability to the covenant community.This article was presented in an earlier version as the Spring Faculty Lecture at Southeastern Baptist Theological Seminary on March 1, 1979.     

Self‐supervision,surveillance and transgression

Transgression is not only an inevitable part of systemic supervision but is also necessary if we are to work towards innovative and inclusive supervisory and therapeutic practice. Defying culturally generated ‘rules’ of systemic practice can allow for more relevant and productive ways of talking. Systemic practitioners are increasingly finding themselves trying to practice systemic therapy in employing authorities and training courses which are dominated by inflexible professional narratives and manualised procedures. Our profession is committed to ethical inner and outer dialogue, to self‐ and relational reflexivity as distinct from the rule‐bound surveillance culture in which we live and work. Systemic supervisors and therapists may find themselves at odds with monological institutional discourse and attempts from within our own profession to manualise practice. I introduce examples from supervisory conversations to illustrate how supervisors can develop more culturally sensitive practices through supporting practitioners to hear and have heard their own marginalised and oppressed voices and those of their clients.