INCREASING THE INDEPENDENT RESPONDING OF AUTISTIC CHILDREN WITH UNPREDICTABLE SUPERVISION

We investigated the role of predictable versus unpredictable supervision on the independent task responding of three autistic children. In a predictable supervision condition, the therapist was present in the setting for a regular period of time and then was absent for the remainder of the session. In an unpredictable supervision condition, the therapist's presence was scheduled on a random, intermittent, and unpredictable basis throughout the session. The multiple baseline analysis showed that the unpredictable supervision produced much higher levels of on-task responding during the therapist's absence for all three children. Analysis of work completed during the therapist's absence also favored the unpredictable supervision condition. The results are discussed in relation to the literature on generalization and educational practice.     

The Group Therapist's Absence and the Substitute Leader

When a group is led by a single individual the therapist's absence creates a management problem. This article presents several options for the solo leader. The author has used a substitute leader, and this experience is presented and evaluated. Discussion includes selection of a substitute, group preparation, ongoing use of the substitute, and benefits of this alternative for the management of the leader's absence.     

Love in the counter-transference: The uses of the therapist's excitement

SUMMARY

The psychoanalytic tradition has always had difficulty with the question of the therapist's sexual feelings toward the patient. This paper traces that difficulty: from Freud's original struggle to replace moralism with a psychoanalytic mode of understanding, to the more recent literature on countertransference which still seems particularly averse to the possibility of the therapist's sexual experience. By way of a discussion of a psychoanalytic psychotherapy, I argue for the sometimes central therapeutic role of the therapist's experiencing, and then containing, excitement.     

‘The Ancient Cult of Madame’: when therapists trade curiosity for certainty

An experience in which the author followed his own objectives rather than the patient's, leading to a tragic end, is evoked as a frame for the presentation and discussion of a family treatment where the therapeutic process led by the therapist may have exceeded the needs and expectation of the family members. This is followed by a discussion about potential problems caused by a therapist's fascination for family stories, since its effects may be epistemologically discontinuous from, if not contradictory to, Cecchin's recommendation for ‘curiosity’ as a central dictum of the therapist's stance.     

Overcoming My Model of Goodness as a Psychotherapist

Summary

The case of Tina is presented to examine one therapist's countertransference issues with a female client who had features of a Borderline Personality Disorder. The therapist's emotional reactions to this client's raw expression of anger and frustration are explored. The discussion also emphasizes the struggle of the therapist in resolving her discomfort with this client and in setting therapeutic boundaries.     

A Sense of Orders

This paper provides an introduction to some of the basic concepts of the provocative French psychoanalyst Jacques Lacan. It illustrates the ways in which these concepts color the therapist's understanding of the patient as the therapist's attention is guided by the patient's expressions of thought and feeling. The response of the therapist is motivated by the interface which develops between this understanding and theoretical underpinnings. Clinical vignettes illustrating Lacan's mirror stage and his three basic orders, the Real, the Imaginary, and the Symbolic punctuate the explanations of these concepts. The paper weaves observations on the signification of language with examples of clinical interpretations.     

Addictive states of mind

This paper explores the meaning of the pregnancy of the therapist as a challenge to the maintenance of the setting for therapy. The patient I shall describe was born ‘black’ in a ‘white’ family and was thus a challenge to her father's sense of paternity and her parents as a couple. She was the visual evidence of an infidelity. The problem had been denied in various ways, going as far as the attempt to deny her very existence. The therapist's pregnancy signified a betrayal of the ideal of a stable setting which was compounded by an earlier absence through illness. This ‘breaking of rules or promises' was then the setting for a re-working of the patient's story.

Setting, it is argued, can helpfully be seen as the mental space created by the partnership within the therapist between maternal and paternal relating to the ‘baby’ of the therapy. This enables a sense of negotiation and relationship in the creation of setting, which can include disruptions and other babies. At the same time the therapy had to work with a fundamental issue of illegitimacy or lack of belonging and the therapist's response to this. The ‘rules' of setting are a means to ensure a place to belong or attach to, but this work emphasized ‘setting’ and belonging as issues of relationship supported and enabled by our rules of engagement, but not reducible to them.     

Saudi therapists' lived experience of self-awareness

Self-awareness and self-reflection in psychotherapeutic processes have been critical components for effective counselling and psychotherapy. However, little qualitative research in Saudi Arabia has been conducted that aims to explore the therapist's subjective experiences of the self in their professional work. Therefore, the purpose of this phenomenological study was to understand the therapist's self-awareness within psychotherapy, by focusing on the therapist's lived experience of self-awareness and exploring how therapists recognise themselves as an integral component of the therapeutic relationship. Semi-structured interviews were conducted with six experienced and accredited psychologists with at least three years of clinical experience, and the qualitative data were analysed using interpretative phenomenological analysis (IPA). Five superordinate themes emerged from the data; that is, development of the professional self, use of self, self-oriented, supervision and experience. This study provides an understanding of the therapist's self in psychotherapy, as it shows that self-awareness is important for therapists to manage their feelings, thoughts and behaviours in meeting with clients and that it is a valuable resource for a therapist to become aware of and reflect upon the process within oneself. This understanding is integrated into the training programmes in counselling psychology, especially in the areas of self-awareness and personal development.     

Reply to Panel Follow-up Questions

When both therapist and client share a traumatic event, there are multiple levels of vulnerability to traumatization for the therapist. Our personal vulnerability is not only a backdrop for our clinical work but also an acknowledged fact in many therapeutic relationships, a situation that changes the frame of the work. In addition to clinical challenges, shared trauma increases a therapist's vulnerability to vicarious traumatization; VT is defined as the negative transformation of the therapist's inner experience as a result of his or her empathic engagement with and responsibility for a traumatized client. Emphasizing the importance of awareness, self-care, meaning, and community, the article summarizes important steps to anticipate, address, and transform the therapist's experience of vicarious traumatization.     

The internal world of the juvenile sex offender

This paper explores the consequences of the therapist's two successive pregnancies on a female patient. The second pregnancy was felt to be particularly difficult and disturbing. One of the central reasons was that after the patient's birth, the mother had a disabled child, followed by a stillbirth and soon after that the father left to marry another woman. Using Freud's concept of deferred action I will argue that my second pregnancy revised these earlier traumatic experiences.

The patient seemed to have incorporated and identified with a damaged maternal object that at the time of the original trauma was left husbandless, depressed and suffering from panic attacks. Although the therapist's healthy pregnancies seemed to reassure temporarily, it was difficult for the patient to hold onto a view of a helpful and productive therapist, one separate from this damaged internal mother. This was particularly so during and after the second pregnancy, where there was a marked absence of an idea of a third object, a father or a husband, who could help the patient deal with this pregnancy, her only escape was to retreat and act out.

The acting out was in part identification with a fleeing father and in part a defence against the absence of such a third object, so that it was used as a way of avoiding claustrophobic feelings of being trapped with the damaged mother. Her feelings of triumph then produced much guilt, and impeded reparation.

Another important issue that two successive pregnancies bring, are feelings of guilt in the therapist for exposing the patient to two major disruptions. In this patient's case it exacerbated the internal reality of a damaged maternal figure.     

Psychotherapeutic work with refugees: Understanding the therapist's countertransference

Abstract

Most therapists are chosen to work with refugees because they speak the language or come from the same cultural or racial background and/or have had experiences which resonate with those of the client. They are often people who can easily understand the clients' experiences, which creates interesting and potent therapeutic dynamics. They can offer a great deal of support to the person, but often with the high risk of over-identification. This paper is an attempt to examine from the therapist's perspective the complex dynamics involved in working with refugee clients. It is a collection of thoughts and feelings expressed in psychotherapeutic and supervisory work by different types of refugee mental health workers. It is an attempt to understand the therapeutic relationship further by focusing on the therapist's psychological response to the client. The paper will outline briefly some of the common themes reported by refugees, but the primary aim is to focus on the therapist's countertransference feelings. Countertransference in this context is defined as a personal psychological response, as well as consisting of socio-political components.     

Freud

The author explores the evidence-base and selection criteria for a short-term supportive dynamic approach for patients whose psychological mindedness and quality of object relationships is low. Illustrating this approach with a case example he outlines the central features of Supportive Dynamic Therapy. He describes a psychodynamic conceptual and developmental framework that can be used to guide the therapist's interventions and responses, and modulate the patient's anxiety. A dynamic focus presented in the form of a central issue is shown to have a significant function both in containing the patient's anxiety, and in giving shape to the therapist's efforts to support the patient's ego-strengths and adaptive abilities. The therapeutic work can be seen to result in an alteration in the trajectory or reiterating pattern of the patient's life.     

The rescuing therapist: A duplication of the pathogenic family system

Abstract

Rescuing is a saving behavior occuring in pathogenic families which is often duplicated by family therapists. Rescuing, if not confronted and explored, leads to frustration and burn—out in families and therapists. This paper explores the dynamics of rescuing behavior in families, how it is replicated by a therapist's attempts to rescue, and how the impetus for these attempts are derived from the therapist's own family of origin. The value of exploring the need to rescue is demonstrated by use of a case example. Countertransference issues and their resolution through the conscious differentiation between rescuing and real help are also explicated.     

Threats of suicide

For patients in treatment, how do suicidal feelings emerge, how do we judge the seriousness of suicide threats and what do we do? The literature on suicidal thinking, suicidal threats and suicidal acts is reviewed as well as some of the accumulated statistics for adults, adolescents and children. Some treatment principles and countertransference reactions are presented. The values of the therapist and the therapist's feelings toward death are seen as coloring the therapist's reaction to suicidal patients.     

Spitting,kicking and stripping: technical difficulties encountered in the treatment of deprived children

The technical difficulties posed for the child psychotherapist working with children who have themselves experienced violence and abuse are addressed. A distinction is drawn between violence in the service of communicating about such experiences and violence that arises from more perverse aspects of the patient. The therapist's need to pay close attention to his counter-transference is emphasized. From an example of a single session we see the therapist's struggle to receive the communicative aspects of extreme acting-out behaviour at the same time as creating a safe setting in which thinking can take place.     

Exercise and Movement as an Adjunct to Group Therapy for Women with Chronic Mental Illness

Abstract

Feminist therapists value the empowerment of clients and the appropriate sharing of the therapist's institutionalized power. As therapists who are also “mandated reporters,” we are obligated under certain circumstances to use our power to warn potential victims of harm, to prevent clients from harm to self or others, or make reports to institutions which have a great impact on clients' lives. Using four case examples, this paper will present clinical situations where the use of the therapist's power interfaces with homophobia, racism, and paternalism in the lives of low-income clients.     

Addressing the Person of the Therapist in Supervision: The Therapist's Inner Conversation Method

In this study a method of retrospective case supervision is presented aimed at helping the supervisee to become a better self‐supervisor. The method pays special attention to the therapist's self‐reflection and has the therapist's inner conversation as a central concept. The starting point of the method is an assignment in which the supervisee reflects on a case using a tape‐assisted recall procedure. The method helps trainees to develop experiential expertise to become more flexible and effective therapists. A case example of one training group of novice family therapists illustrates the use of the method.     

The Whole of the No-thing: Reply to Commentary

We attempt to apply our conceptualization of the absence–presence dialectic and the capacity to disappear to our understanding of the experience and the treatment of trauma. Francisco Gonzalez challenges us to encounter the place of destruction and void where the absence is simply uncontainable. We suggest that the transformational meeting place between patient and therapist entails a reawakening of the movement between absence and presence, being and not-being, some-thing and no-thing, which were previously a frozen or derailed dialectic. The therapist's capacity to surrender to the temporary nihilation of the self within the therapeutic relationship is seen as the turning point in the reestablishment of movement and the creation of meaning.     

The dream of dreams

Abstract

This paper investigates the relationship between the therapist's use of the dream and the patient's use of the dream, both inside and outside the formal therapeutic setting.