Therapist Self-as-Context and the Curative Relationship

This article discusses how the way the therapist relates to his or her personal responses to client material during the session contributes to making the relationship with the client an effective tool for treatment. Ideas from third wave behavior therapy are used to describe aspects of therapist involvement in the relationship and modes of therapist awareness of inner responses. In two vignettes, negative client reactions to an intervention bring problematic therapist material to the fore. Both cases highlight how the stories the therapists spun about themselves as professionals and persons could easily have limited their effectiveness in responding to the material. The vignettes also illustrate how clinicians can overcome personal meanings and judgments to access a more productive mode of interacting with the feelings a critical incident in the relationship evokes in them. It is argued that observing their own content from a psychological distance makes it possible for clinicians to use their feelings without getting caught up in them. These same feelings may then help the therapist perceive how the incident relates to the client’s daily life problems. The therapist’s engagement in a sense of self-as-context is described as a therapeutic stance that provides the psychological distance needed to help overcome alliance ruptures and other potential gridlocks and which may transform the therapist’s inner response to client content into a tool for addressing important client issues.     

Therapeutic Assessment in Psychological Triage Using the PAI

This case illustrates the utility of incorporating therapeutic assessment in a triage context that typically involves a focus on gathering information. A man referred to our clinic by a local mental health center was seen by our assessment team for a triage that includes the administration of a single psychological test, the Personality Assessment Inventory (PAI). Although this triage must rapidly gather information to determine client suitability and treatment assignment, we still attempt to work with clients to collaboratively develop goals for this assessment that include addressing questions that are central concerns for the clients. In this case, the test results suggested a severe disorder that accounted for many phenomena that he had been experiencing but had apparently been reluctant to share. The information gathered led to a referral to a different treatment program that could provide pharmacological and more intensive forms of treatment. However, the collaborative bond formed between the assessor and the client during this triage was sufficiently strong that it was our assessor to whom the client turned in a subsequent crisis precipitated by a symptomatic exacerbation. This case illustrates complementary information gathering and therapeutic goals of assessment even in the context of a brief assessment.     

Psychologist as Mentor and Detective in the Mirror of the Soul

A case study is presented of a client, involved in business dealings and personal relationships with members of organized crime, who upon looking into his mirror one morning recognized for the first time that his life was quickly slipping away. Unless he broke free, he decided, by doing something bold and outrageous—in the style of his free-spirited and violent youth—he was doomed to a depressive existence for the remainder of his days. He stalked women by night. Disturbed by a series of frightening dreams of his involvement in the murder of a stalked and raped woman, he approached the author for psychological help. During the course of treatment it became apparent that the client lacked a sense of personal goodness. An exploration of the problematic nature of virtue and constructive behavior in psychotherapeutic theory is presented here, together with a rationale for the role of the therapist as mentor as well as therapist for people who lack early and present experiences with constructive role models.     

Coming to an end: A case study of an ambiguous process of ending psychotherapy

Aim: When the duration of therapy is not preset and the outcome is a matter for negotiation, the decision to end psychotherapy will be an experiential concern for the two participants. This case study draws attention to how ambiguities may be settled in a process where ending is initiated by the therapist and resisted by the client. Method and analysis: The actual case was strategically selected as exceptional owing to a combination of circumstances. The client and the therapist had developed a ‘good enough’ alliance (WAI) and reached a ‘good enough’ outcome (OQ‐45), and still the client felt she was far from finished. A close inspection of interactional data in sessions together with both clients' and therapists' reflections in post‐therapy interviews elicited information about both substantial content and structural aspects of this complicated process of ending. Findings and discussion: The discrepancy between therapist and client was not addressed, but rather postponed and revisited again later. Structural elements like preparations for a break for vacations and reducing the frequency of sessions were used to test experiential qualities, such as how the client managed life without therapy. Carefully preserving a ‘good enough’ emotional bond through the negotiations seemed important to both parties. Significantly, the client's autonomy was interpreted as the final proof of improvement and the client came to a point where she could affirm that she had got better only by accepting that treatment was coming to an end.     

Functional analytic psychotherapy and the treatment of obsessive compulsive disorder

This paper argues that Functional Analytic Psychotherapy (FAP) can contribute to the treatment of Obsessive Compulsive Disorder (OCD). FAP is a behavior analytically informed approach to talk-therapy, developed by Kohlenberg and Tsai. It uses natural occurrences of clinically relevant behavior in the client-therapist relationship to promote therapeutic change. A selection of vignettes of client-therapist dialogues involving two clients with OCD is discussed. The examples show how natural interactions between therapist and client can be used to bring therapeutic technique closer to the natural occurrences of obsessive-compulsive behavior. Furthermore, the fragments illustrate that FAP can encompass exposure and response prevention. Therefore, the in vivo learning during the session as promoted in FAP can be an asset in the treatment of clients with OCD, and it deserves attention in future treatment research.     

"Am I going crazy, doc?": a self psychology approach to therapeutic assessment

In this case study, we explore the effectiveness of Therapeutic Assessment with a severely disturbed 25-year-old man, referred by his therapist, following Finn's (2007; Finn & Tonsager, 1992, 1997) model. This patient-therapist pair had been working together for approximately 2 months, but the therapy had ceased to progress. The therapist requested a clearer picture of his patient's affective functioning, interpersonal functioning, and self-functioning that might facilitate more effective treatment. Through a collaborative assessment process informed by the principles of Kohutian self psychology, the evaluator and patient slowly formed a working alliance that proved useful for the eventual communication to the patient of his psychologically tenuous reality. This case illustrates the utility of a collaborative, multimethod Therapeutic Assessment with a severely ill patient and the use of Therapeutic Assessment by a less experienced clinician.     

Language: The art of therapeutic communication

Abstract

This article shares insights into the processes of suggestibility in the interaction between client and therapist. The article also draws on the work of Yapko and Langs and the insights of the author himself in order to make suggestions on how clinical practice and its supervision could be improved by greater scrutiny of the content of client-therapist interactions.     

Dialogue in Therapy's "Borderzone"

This article explores some implications of practicing therapy from a discourse perspective. In particular, the dialogues of therapy are portrayed as a context in which client and therapist practice culture. Therapy, from this perspective, can optimally take place in an imaginary dialogic meeting place--a "borderzone"--wherein the discussions of therapy can occur in respectful ways. Discursive therapists are encouraged to see the differends, or potential stuck times of therapy, as times to turn to alternative discourses to keep the dialogue resourceful and collaborative.     

个体心理治疗的复杂性

本文尝试从复杂适应系统理论的角度对个体心理治疗的复杂性加以阐述。依据复杂适应系统理论,心理紊乱并不必然是心理健康的敌人;在个体心理治疗的动力发展过程中,治疗师与来访者相互适应突现配对联盟,来访者的心理变化或新的心理结构的突现具有不可预测性;心理治疗的目标是使得僵化有序、封闭、适应不良的系统朝向日益复杂、开放、灵活适应的状态转化。复杂适应系统理论为探索人类的心理体验与发展提供了新的思路和方法。     

“Am I Going Crazy,Doc?”: A Self Psychology Approach to Therapeutic Assessment

In this case study, we explore the effectiveness of Therapeutic Assessment with a severely disturbed 25-year-old man, referred by his therapist, following Finn's (2007; Finn & Tonsager, 1992, 1997) model. This patient–therapist pair had been working together for approximately 2 months, but the therapy had ceased to progress. The therapist requested a clearer picture of his patient's affective functioning, interpersonal functioning, and self-functioning that might facilitate more effective treatment. Through a collaborative assessment process informed by the principles of Kohutian self psychology, the evaluator and patient slowly formed a working alliance that proved useful for the eventual communication to the patient of his psychologically tenuous reality. This case illustrates the utility of a collaborative, multimethod Therapeutic Assessment with a severely ill patient and the use of Therapeutic Assessment by a less experienced clinician.     

Exploitation in therapy and counselling: a breach of professional standards

Exploitation in therapy and counselling may occur in only a minority of cases, but when it does, its effects are potentially damaging to both the client and the profession. Exploitation in therapy may take the form of psychological, covert and overt abuse. The most reported form of abuse of the therapeutic relationship is of a sexual nature. However, psychological abuse usually forms the backdrop to sexual exploitation, preceding and perpetuating the sexual involvement. Sexual exploitation in therapy is an abuse of the power imbued in the therapist by nature of his professional role. It allows the therapist a sexual gratification which he would not have been likely to achieve outside the therapeutic relationship. The prevention of sexual exploitation in therapy is an issue of concern to training, employing and professional organisations who seek to maintain high standards of counselling delivery. Determining the variables which may contribute to exploitation is fundamental to avoiding its incidence. This paper discusses the factors underlying the use of therapy and counselling as a medium for therapist abuse. It examines (i) the prevailing conditions for abuse to occur, (ii) how the therapist overcomes client resistance, and (iii) the implications for the maintenance of professional standards.     

What Torture Survivors Teach Assessors About Being More Fully Human

This article illustrates the complex sociocultural components in the forensic psychological assessment of a young Ethiopian woman's claim for political asylum due to a well-founded fear of persecution and for relief under the Convention Against Torture. It draws attention to the subtle social and cultural influences in the practice of forensic psychological assessment with an emphasis of reflective practice, which is contextualized in the interpersonal theory of Sullivan. In the interpersonal approach, the essential work of the assessor is to pay careful attention to the microinteractions between the client and the assessor as reflections of the interpersonal (meaning social and cultural) processes, eschewing the illusion of objectivity.

In this case study, I illustrate the particular cultural dilemmas for client and assessor in conducting a forensic assessment of psychological trauma, including cross-cultural, gender, and legal difficulties in arriving at an informed, objective, and compassionate assessment of an individual seeking asylum after an especially brutal experience of torture. I argue that collaborative therapeutic assessment methods adapted for forensic practice offer an approach to assessment of psychological trauma that provides more accurate and compassionate assessment than so-called neutral standard forensic assessment practice.     

Seeing in the Dark: A View into Dissociation and Healing

In this paper, I will explore the role of art-making, the experience of trauma and dissociation, and the process of working with self-states from an analytic and creative frame. Relevant literature on dissociation, trauma, and the use of art will be discussed. A case involving my work with an adolescent girl who had experienced sexual abuse from a family member will be shared, with an emphasis on the meaningful role images played during the therapeutic process. Both Jungian and psychoanalytic models of conceptualizing and working with dissociation are included, following Donald Kalsched’s (2013) recommendation for a “binocular stance” to treatment, including both a focus on the inner, intrapsychic world and the interpersonal, relational realm, and how art images both illuminated and expressed these realms. Within the therapeutic process, art images allowed the therapist a view into the client’s unconscious process, and created a meeting ground for dissociative barriers to be gradually seen, felt and known, by both therapist and client. The experience of dissociation, in images and in session, provided a reference point for myself and my client, Taylor, to develop a shared understanding and a framework for growth.     

Three fragments on trauma and time

How does trauma influence a client and a therapist’s experience of time in time-limited therapy? The therapist must first work to understand and remain responsive to the different registers of time now operative following the traumatic event. This paper contends that in the immediacy of trauma, hallucinatory wish-fulfilment oblivious to the structuring conditions of time and space appears to dominate. In chronic traumatic states, time appears to circle in a narrow compass, buffering between a cluster of moments surrounding and including the moment of traumatic rupture – as if struggling to re-establish a secure connection with linear time. The three clinical fragments presented attempt to describe different experiences of traumatic bereavement and the felt movement of time within them. The death of another confronts us not only with their loss but with our own mortality – the time we have lived and the time we have left. It is not surprising, therefore, that an individual's otherwise fluid transitions between different temporalities are disturbed in the aftermath of traumatic bereavement. The therapist’s capacity to regulate tempo when the client’s subjective experience of time is dysregulated offers an important means of containment. The aim of the therapist working with the traumatically bereaved client is to develop collaborative understanding to get thinking moving again and to gradually help the client unpin time, moving it beyond the confines that it occupies in trauma.     

Testing Case Formulation Hypotheses in Psychotherapy: Two Case Examples

We describe two cases that illustrate and demonstrate the effectiveness of a case formulation–driven approach to psychotherapy in which the therapist, in collaboration with the patient, develops a hypothesis (formulation) about the psychological mechanisms that cause and maintain the patient’s difficulties, uses the formulation to guide intervention, and collects data to test the formulation and evaluate the effectiveness of the intervention plan. As shown by the cases reported here, a key strength of this collaborative empirical process is that it enables the patient and therapist to quickly determine when a treatment is failing and take action to rescue it.     

Utilizing artistry in a therapeutic relationship

Abstract

In many humanistic approaches, therapeutic change involves utilizing the relationship between the client and therapist as a tool for personal growth. Like any relationship, the therapeutic relationship is one that is co‐created between those engaged in it, namely, the client and the therapist. Utilizing this co‐created relationship requires a sense of artistry on the part of the therapist. A therapist must be willing to engage in this meaningful relationship with the client. A therapist must also be aware of the personal values that he or she brings into therapy, and how they influence the therapeutic relationship. Finally, a therapist must acknowledge the power that the therapist and the client possess in the relationship, and understand how that power can be used to validate and invalidate the therapist's and the client's personal meanings. These aspects of therapeutic artistry are discussed and the use of therapeutic artistry in Eron and Lund's (1996) narrative solutions approach is presented.     

Resolution of a drug abuse problem in a private practice setting

This case study involves a 27-year-old male who began therapy in an effort to understand his drug abuse. As an essential part of treatment, the client was asked to abstain from drugs. In doing so, he began to experience and understand the feelings of anxiety which drugs had defended him against.The therapeutic technique used provided for the therapist to establish an interaction with the client by playing the dual role of the supportive, yet assertive father and the soothing, yet separation-encouraging mother. Consequently, the client was able to experience, confront and work through his anxiety.     

"I-I" AND "I-ME": TRANSPOSING BUBER's INTERPERSONAL ATTITUDES TO THE INTRAPERSONAL PLANE

Hermans' polyphonic model of the self proposes that dialogical relationships can be established between multiple I-positions1 (e.g., Hermans, 2001a). There have been few attempts, however, to explicitly characterize the forms that these intrapersonal relationships may take. Drawing on Buber's (1958) distinction between the "I-Thou" and "I-It" attitude, it is proposed that intrapersonal relationships can take one of two forms: an "I-I" form, in which one I-position encounters and confirms another I-position in its uniqueness and wholeness; and an "I-Me" form, in which one I-position experiences another I-position in a detached and objectifying way. This article argues that this I-Me form of intrapersonal relating is associated with psychological distress, and that this is so for a number of reasons: Most notably, because an individual who objectifies and subjugates certain I-position cannot reconnect with more central I-positions when dominance reversal (Hermans, 2001a) takes place. On this basis, it is suggested that a key role of the therapeutic process is to help clients become more able to experience moments of I-I intrapersonal encounter, and it is argued that this requires the therapist to confirm the client both as a whole and in terms of each of his or her different voices.     

Therapist activities preceding therapy setbacks in a poor-outcome case

Progress in psychotherapy is typically irregular, as advances alternate with setbacks. This study investigated the therapist’s activities prior to two main types of setbacks, one involving the client following therapist proposals and one involving the client failing to follow from therapist proposals, in the case of a poor-outcome client treated with a linguistically-oriented kind of cognitive therapy. Setbacks were defined as decreases of at least one level on an index of therapeutic progress, the 8-level Assimilation of Problematic Experiences Scale (APES), in adjacent client passages. Therapist activities were coded in 361 setback episodes that each included a client pre-setback passage, a therapist passage, and a client setback passage; both client passages had been previously rated on the APES. The main categories of therapist activities showed distinctive patterns in relation to the two main types of setbacks, the therapeutic zone of proximal development and the balance strategy. The two main patterns were described as an exploratory and a challenging configuration. These patterns of therapist activities and setbacks showed how the therapist seemed to persevere with approach-guided interventions while this poor-outcome client continued to have setbacks to low APES levels.