Family therapist authenticity as a key factor in outcome

The authors explore various arguments for and against therapist self disclosure and relate these to theoretical school and therapist style and personality. Several case vignettes are used to highlight the appropriate and efficacious revelation of therapist's thoughts, feelings and reactions to the patients and their behavior. A review of the recent literature on this controversial topic is included. The theme is that in almost all therapies, except in psychoanalysis where it is counterindicated, the therapist's selective dynamic use of his own perceptions, experiences and values in a genuine and committed fashion contributes positively to the therapeutic outcomes.To thine ownself be true And it must follow as the night the day Thou canst not then be false to any man. (Hamlet, Act I)     

Amelioration of transference resistance: substitute therapists in milieu group psychotherapy

Building upon Wolf's (1949) notion of the use of an alternate session in group psychotherapy, this paper suggests that an alternate therapist substituting for an absent regular therapist in milieu group psychotherapy can facilitate similar therapeutic benefits. The mechanism of this process of overcoming transference resistance is seen as twofold: (1) sessions with a substitute therapist allow patients to confront the infantilization often present in a milieu setting and experiment with more autonomous ego functioning. (2) Sessions with a substitute therapist create conditions which are apart from the ongoing process of the therapy group, thereby allowing for a therapeutic splitting process to develop wherein transference feelings about the regular therapist can be expressed to his or her "alter ego." Several case vignettes are presented in order to illustrate the clinical utility of a substitute therapist.     

Love and the therapeutic process

This paper deals with the nature of love that can be present in the person of the therapist as well as how it can express itself in the therapeutic effort. It also takes up certain errors that can occur as a result of the misunderstanding of the terms as well. There are those who lean toward making therapy an overintellectualized process. The point of view is presented that for psychotherapy to have its full value, the emotions need awakening and structuring for the benefit of the patient's individual life contributions as well as for the benefit of those he will associate with during his lifetime.     

The therapist's inner conversation in family therapy practice: some ideas about the self of the therapist, therapeutic impasse, and the process of reflection.

In this article, a distinction is made between the outer therapeutic conversation and the therapist's inner conversation. The therapeutic conversation is a circle of meaning in which both the therapist and the clients play a part. The therapist's inner conversation is described as a negotiation between the self of the therapist and his role. In this process of negotiation the therapist has to take seriously, not only his observations, but also what is evoked in him by these observations, that is, images, moods, emotions, associations, memories, and so on. Furthermore, therapeutic impasse is conceptualized as a paralysis of the circle of meaning and of the therapist's inner conversation. A process of reflection is proposed as a way out of the impasse. In that process, the inner conversation of the therapist is externalized with the help of an outsider. In the final part of this article, a case study illustrates the importance of these ideas for the family therapy practice.     

Sexual misconduct in psychotherapy: reactions to a consumer-oriented brochure

Reactions of subjects to a brochure addressing the topic of sexual intimacy in psychotherapy was assessed. Fifty-four psychotherapy clients and 52 licensed psychologists responded favorably to the brochure, with the majority indicating that the brochure should be made available before therapy begins or during the first session. Potential clients (120 college students) read either the brochure on sexual misconduct or a control brochure containing general information about psychology. Subjects who read the sexual misconduct brochure showed increased ability to understand what is appropriate and inappropriate therapist behavior, see unwanted touch as nontherapeutic, regard a therapist talking a lot about his or her own sex life as inappropriate, view sex in the therapeutic relationship as inappropriate, and intend to behave assertively within the session if their therapist's behavior should make them feel uncomfortable. Subjects who read the control brochure showed no such changes.     

Spontaneous Moments and the Domain of Non-Verbal Communication

Abstract

This paper investigates the impact of non-verbal interactions and spontaneous encounters on the therapeutic process and on a client's structural and behavioral patterns. The following case vignette concerns a client who presents with a pattern of non-verbal relational schemas based on his early traumatic experiences. The non-verbal and verbal role reenactments that unfold between client and therapist will be examined from an intersubjective, dialogical and self psychological perspective. Finally, the paper will explore how important therapeutic shifts may occur by attending to and working through these non-verbal aspects of the treatment, leading to new relational structures.     

Mass psychology of the led and the leaders

Abstract

Some salient features of a Sullivanian perspective are given as a background for a discussion of the case of Anna. Lived experience is mentioned as of equal importance as fantasy. Technically, analytic inquiry in the form of questions is stressed. In his review of the case presentation, the author observes that too much emphasis is given to content, compared to form. He notes that the therapist does not report key transference and non-transference interactions with the patient and further suggests that the patient still has significant narcissistic problems. He suggests that it is time to confront the patient with her characterological ways of relating to the analyst.     

Separation and loss in psychoanalytic therapy with borderline patients: Further remarks

This paper is a continuation of an earlier one concerning borderline patients, and I can recapitulate only a few of the many areas touched upon here. The borderline individual is faced continually with the threat of loss, either of his tenuously established individual identity, through fusion with the other person, or of his fragile interpersonal relatedness, through uncontrollable flight into autism of psychotic degree. A basic theme in one's work with these persons is that of unconscious, fantasied omnipotence, variously an aspect of the patient's unconscious self-image or projected into the therapist. The acting-out which the patient does consists in his inflicting loss, deprivation, and other forms of injury upon his introjects of part-aspects of the therapist. The grief involved in the relinquishment of so-called bad introjects is discussed. The patient early in therapy is aware of his inability to grieve, and endeavors to conceal this deficiency by spurious emotionality. I give examples of patients' manifesting regressive dedifferentiation to fusion with elements of the nonhuman environment, as an unconscious defense against feelings of separation and loss. Effective therapy with these patients involves the therapist's deeper working through of his own losses. The significant losses occurred so early in these patients' lives that the therapeutic exploration of these areas may enable the therapist to gain access to comparably early losses on his own part, losses from a developmental era which many a training analysis may not have explored at all adequately.     

‘Get me out of this dream!’: making a therapeutic alliance and working in the transference with a psychotic adolescent boy

This paper discusses the challenges of struggling to build and maintain a therapeutic alliance with a psychotic adolescent boy who did not share an allied perception of reality with his therapist, and who insisted that his therapist did not exist. The paper poses the question of whether, under such circumstances, it is ever appropriate or tolerable to make transference interpretations. Drawing on detailed clinical material, the author attempts to make sense of how it was possible to make some contact with his patient, given these technical difficulties.     

Parent as Saboteur in the Therapeutic Treatment of Children

Children present some unique challenges to the therapist regarding treatment. Unlike adult patients, they are obviously still dependent upon the parent for transportation, the payment of fees, and the success or failure of treatment. Thus the parents make the ultimate decision to continue or terminate treatment. But sometimes a parent's characterological problems are activated by their child's treatment. These diagnostic problems can be classified as envy, jealousy, competition, and narcissism. When any or all of these unresolved parental issues are touched by the treatment of their child, some parents become determined to sabotage therapy, despite the necessity of the treatment for their child. The author's intent is to identify the parental characterological issues for sabotaging therapy through both a theoretical analysis and a discussion of the particular methods parents employ to achieve this end. Identification of the various strategies for handling hostile parents and elaboration of various methods that the therapist may employ are discussed when parental sabotaging of treatment becomes a problem. Recommendations for particular interventions are suggested to illuminate the challenges the therapist faces with those parents whose intent is to sabotage treatment.     

The making of an abuser

This paper investigates how it is that a child has become an abuser, and by what means that process may be deconstructed. We know that abusers generally have a childhood history of abuse, though not necessarily sexual. Since not all children who have been traumatised repeat those patterns, and inflict abuse on others, then something must have happened for these particular children in response to their abuse. The author elaborates the view that there is no such thing, to paraphrase Winnicott, as ‘an abused child’ – no such child, that is, separate from the world of the relationships that formed him. He draws on the conceptualisation by Bentovim of an interlocking set of roles described as a ‘trauma organised system’; this notion reflects the fact that the child is a product not just of his specifically traumatic experiences but of a milieu in which power and control is exerted by someone who has typically succeeded in neutralising any caring function in a family in order to bring about the exploitation of a child. Clinical material is presented from the intensive psychotherapy of a nine-year-old boy, who happened also to be a refugee, for whom abusive family dynamics dominated his internal world. He was found to have identified with the abuser, his own father, in order to escape the pain of his victim self and was threatening to act this out in the treatment, making the therapist into a victim. Management of the treatment setting by the inclusion of a benign parental figure enabled the acting out to be contained. Symbolisation of the child’s inner conflicts became possible through play. As the abuser self was contained so the child’s victim experiences could be processed. The conclusion is drawn that engaging therapeutically with the residues of trauma from the beginning of treatment is essential in working with young people who have abused.     

Descriptive Study of the Socratic Method: Evidence for Verbal Shaping

In this study we analyzed 65 fragments of session recordings in which a cognitive behavioral therapist employed the Socratic method with her patients. Specialized coding instruments were used to categorize the verbal behavior of the psychologist and the patients. First the fragments were classified as more or less successful depending on the overall degree of concordance between the patient’s verbal behavior and the therapeutic objectives. Then the fragments were submitted to sequential analysis so as to discover regularities linking the patient’s verbal behavior and the therapist’s responses to it. Important differences between the more and the less successful fragments involved the therapist's approval or disapproval of verbalizations that approximated therapeutic goals. These approvals and disapprovals were associated with increases and decreases, respectively, in the patient’s behavior. These results are consistent with the existence, in this particular case, of a process of shaping through which the therapist modifies the patient’s verbal behavior in the overall direction of his or her chosen therapeutic objectives.     

The Jerusalem TeleRehabilitation System, a new low-cost, haptic rehabilitation approach.

Survivors of brain injury or stroke can improve movement ability with intensive, supervised practice. Since the hours of supervised therapy with a physical or occupational therapist are limited, telerehabilitation will enable patients to greatly expand the hours that they practice therapeutic exercises. The Jerusalem TeleRehabilitation System (JTRS) consists of patient and therapist systems plus a central server and database connected via the internet. The system can work in two modes: (1) a cooperative mode in which the therapist and patient are online at the same time, and (2) a stand-alone mode in which the patient uses the system on his own. In both cases, the system will monitor the status and progress of the patient and various parameters of his movement abilities, and prepare reports for the patient and for the therapist. From the clinic, the therapist will be able to change the screen seen by the patient and change the level and types of tasks, as needed. Compared to existing systems, our system will have the following advantages: (1) inexpensive and easy to use; (2) remote monitoring and control of the patient's computer by the therapist in the clinic; (3) more detailed analysis of patient status and progress; (4) a "smart" system which self-adapts to the patient's capabilities in real time, increasing or decreasing the difficulty of the exercise as needed; and (5) a central, international database which, by gathering data on many patients over time, will provide the basis for "smart" therapy and will also facilitate coordinated multicenter research studies.     

Clinical differentiation of borderline syndromes from the psychoses

The discrimination of borderline syndromes from the psychoses is often a difficult task clinically. The problem most often arises in the acute setting in which a crisis has arisen--the typical example being that of acute hospitalization. The clinician's task is to assess the patient's apparently psychotic symptoms and behaviors to determine whether they are the manifestations of an underlying psychotic process, or whether they reflect a more or less transient regression from a somewhat higher level of habitual functioning. Some discrimination between these categories is possible even in the acute presentation, since borderline patients only exceptionally demonstrate Schneiderian first-rank symptoms or any other discriminating indices of psychosis. While the differentiation may be clear cut between the psychotic and the higher-order, better functioning borderline, there may be less precision in discriminating between the lower-order borderline forms or transient borderline states and psychoses. We have focused on this area of differentiation in this study. The discriminating indices are both short- and long-term. The differentiation cannot be adequately made without longer-term evaluation of the patient. Nonetheless, on a short-term basis, evaluation of the patient's behavior can point the diagnosis in one direction or other. The presence of a clear precipitant; the presence of intense (often verbalized) anger; the patient's attempts to engage the therapist in an intense, dependent, clinging and demanding relationship, usually in manipulative fashion; the partial, fragmentary, often circumscribed and ego-alien quality of the patient's psychotic productions; the marked tendency to act-out feelings, particularly anger, in a way that gains increased attention and concern from doctors, family, friends, or hospital staff; the persistence of some degree of reality testing and areas of significant realistic functioning; the transient nature of regressive manifestations and the ready reversal of regression in structured environments and with appropriate therapeutic management, particularly adequate limit-setting--all point toward a borderline diagnosis. Moreover, these factors carry an accumulative weight so that the more of these factors that can be validated, the more secure the diagnosis of borderline psychopathology. On a longer-term basis, beyond a few days, one would expect the above indices to be better discriminated. In addition, there is greater opportunity to study patterns of patient behavior--both his interaction with staff and other patients and with the therapist.(ABSTRACT TRUNCATED AT 400 WORDS)     

Client self-image,therapist acting,and the establishment of the therapeutic alliance in a training context

This study examined how clients’ self-image and perception of therapist’s behavior are related to the therapeutic alliance, as well as how these variables change in the psychotherapy process in trainee-led psychotherapy. A total of 164 participants (M = 28.9 years) who attended two semesters of treatment at the Psychology Clinic of Umeå University completed the Working Alliance Inventory (WAI) to evaluate their perception of their alliance with the therapist. They also completed two questionnaires based on the Structural Analysis of Social Behavior (SASB) model to give insight into their self-image patterns and to analyze their perceptions of the therapist’s behavior. The results show that a positive self-image and positive perceptions of the therapist’s actions increased significantly over the course of the therapy, with a corresponding decrease in negative patterns. The alliance scores show that the therapeutic alliance gains significance over time and that it is influenced more by the perception of the therapist’s behavior than by the self-image. The self-image becomes relevant after the mid part of therapy, underlining the role of the therapist in co-creating the treatment relationship. The implications of these results are discussed, and so are directions for future research in other trainee-led settings and samples.     

Object Relations and the Development of Values

Values acquisition as a part of the therapeutic interaction that occurs between client and therapist is a clear and focused representation of what naturally occurs between people who influence one another. As the relationship develops in therapy, and the client begins to trust the therapist, he or she also becomes inclined to emulate that therapist in greater or lesser degrees. From an object relations point of view, a developmental process unfolds between these two people, which reflects the means by which a person realizes his or her value system. The discussion begins with the etiology of identification, because according to this viewpoint, the process described above begins, and is supported by, the dynamics of identification. Referring specifically to the ideas of Heinz Kohut, the authors describe the mechanisms of idealization as the intrapsychic process most basic to the final formation of values.     

Counsellor conflict in managing the frame: Dilemmas and decisions

An essential feature of psychodynamic counselling is a secure frame for the work that holds boundaries as sacrosanct, both to ensure ethical practice and to provide a vehicle through which unconscious processes can be recognized and understood. Conscious or unconscious attacks on the frame are inevitable in any therapeutic relationship, and provide an opportunity for exploration and insight. However such incidents also have an impact on the therapist who must decide how to respond. In order to understand more about the therapist process when there is an attack on the frame, an investigation was carried out into ways in which psychodynamic counsellors manage the difficulties and dilemmas that arise as they try to hold a secure therapeutic frame. Ten counsellors were interviewed using a semi‐ structured interview format during which they were asked about an instance when the frame was challenged and the process by which it was resolved. The resulting dilemmas were categorized using grounded theory. Three categories of dilemmas emerged a) prior to making a decision about how to deal with it, b) after making a decision, and c), as a result of the outcome of the action taken. The nature of the dilemmas and the process of resolving them are reported and discussed.     

Continuing education in humanistic psychology

This article explores the importance of the relationship between a teacher of meditation and his or her student. Mindfulness meditation is receiving a lot of attention in the psychotherapy literature currently. It is generally viewed as a technique that is taught in groups and then practiced individually by clients or participants. What does not appear to be generally understood is that the teaching and learning of meditation is understood in Eastern traditions as intimately related to the relationship that develops between the teacher and student. This, in fact, is very similar to what we are coming to understand about the importance of the therapeutic relationship to the outcome of therapy, regardless of technique or orientation of the therapist. Personal experiences of the author in a relationship with a meditation teacher are compared with those from a psychoanalytic therapy experience. Meditation is construed from this perspective not only as a technique that is learned and practiced but also as an innate human capability that is activated in the context of a very special kind of relationship with a person who has fully unfolded this capacity in his or her own experience.     

After the attempt: maintaining the therapeutic alliance following a patient's suicide attempt

The risk of a patient's suicide is a prominent occupational hazard for psychotherapists. The precise number of patients who attempt suicide while in treatment and then resume therapy with the same therapist is not known, but this situation is a relatively common occurrence in clinical practice. Such scenarios can pose significant challenges to the reestablishment of the therapeutic trust and a workable treatment alliance. The aim of this paper is to identify the challenges facing a clinician treating a patient who resumes therapy following a serious suicide attempt, and to offer guidelines for maintaining the viability of the therapeutic alliance.