Restoring Dyadic Connection in the Face of Multiple Disruptions: Accounting for Vicissitudes in the Therapist’s Capacity for Reflective Functioning

This article describes the working method of our study group comprised of former Chestnut Lodge Hospital therapists and focusing on understanding therapeutic work with severely disturbed adolescents. Using process material from one therapy session, the therapist’s commentary on her feelings and reactions in the session, and the group’s discussion of the work, we explore factors disrupting the therapist’s moment-to-moment capacity to maintain a theory of her own and the patient’s minds. We then discuss what allows her to refind her theory of mind in the face of the patient’s aggressive nihilism and her own sense of loss. Salutary factors included the therapist’s empathy for the patient’s shared sense of grief, the patient’s offering the therapist cues to his inner state, and the dyad’s capacity to tolerate the therapist’s vulnerability in the patient’s presence.     

The Use of Homework in Cognitive Behavior Therapy: Working with Complex Anxiety and Insomnia

Homework, or self-help, is an essential and required part of cognitive behavioral treatment. It offers several opportunities for the therapist to extend and increase therapy contact by having the patient “live” the therapy outside of the consulting room. It can also serve as a measure of the patient’s motivation for therapy or for change. Homework offers the patient an opportunity to practice what has been developed and discussed in the therapy session. By trying out new behaviors, new ideas, or new emotional responses, the patient can make “real” what has been an abstraction in the therapeutic dialogue. The homework becomes an opportunity for gathering data. Inasmuch as the homework grows “organically” from the session content, it is relevant and timely. Homework provides continuity between sessions. Rather than sessions being discrete moments in time, they are chained together by the homework from the previous session being included in the agenda for the subsequent session. The homework can be structured to involve significant others. This is essential in many therapeutic situations, and having the significant others involved can substantially aid in relapse prevention. Finally, effective homework helps to build therapeutic collaboration and afford the patient the opportunity for building self-efficacy. Using several case examples, this paper describes the functions and impediments to using homework in CBT.     

Therapeutic immediacy across long-term psychodynamic psychotherapy: an evidence-based case study

C. E. Hill (2004) recently developed the concept of therapist immediacy to capture discussion by the therapist about the therapeutic relationship that occurs in the here-and-now of a therapy session. This concept has been expanded to include discussion about the therapeutic relationship by both the client and therapist, captured by the term therapeutic immediacy (K. Kuutmann & M. Hilsenroth, 2011). Although prior research has examined the use of therapeutic immediacy across short-term treatment, the present study is the first to examine the use of immediacy across a long-term (4 years) psychotherapy. Also, this is the first study to assess the interrater reliability of therapeutic immediacy, which was found to achieve good to excellent levels across raters. The most frequently used categories of client and therapist immediacy are presented. Finally, the authors provide an in-depth qualitative examination of 5 therapeutic immediacy segments across the treatment judged by the raters to have high levels of depth/intensity (4.5 or higher out of 5) to examine the role of therapeutic immediacy in exploring meaningful treatment issues. Clinical utility, potential limitations, and future research on therapeutic immediacy are discussed.     

The Therapist’s Needs: Beyond Mutual Recognition

Abstract

As early as 1965, Harold Searles argued that therapists’ needs for healing and growth are part and parcel of their work with patients. Since then, the relational movement has corroborated this idea by articulating the healing function of treatment for both patient and clinician. In this article, the authors examine therapists’ needs that have been overlooked or those that have not been considered fully in the literature. Using various ideas related to the concept of what the authors call therapeutic freedom, this article argues that clinicians must strive to adopt a therapeutic vision that aims to loosen their own ties to safe, familiar modes of engaging with patients, particularly in moments of enactment or impasse. The authors elucidate these ideas with case material from their clinical work and show how embracing various forms of therapeutic freedom results in a type of mutual surrender on the part of both patient and therapist, creating opportunistic conditions that generate therapeutic action and new possibilities for the dyad.     

Therapeutic relationship and progress in the first six sessions of individual psychotherapy: A panel analysis

The temporal nature of the associations between client-rated therapist empathy and acceptance, and both client-and therapist-assessed therapeutic progress at sessions 2 and 6 were examined pairwise with cross-lagged panel correlatation (CLPC) and linear structural relationships (LISREL) analyses in 37 clients treated in weekly individual sessions of long-term psycoanalytic and person-centred therapy by 37 experienced therapists. Although none of the cross-lagged differences in the three CLPC analyses which met the necessary conditions for interpretation were significant, two of them approached it, suggesting that session 2 client-rated progress was a stronger determinant of session 6 therapist empathy and acceptance than vice versa. However, the LISREL analyses indicated that while session 2 client-rated progress was unrelated to session 6 therapist acceptance, session 2 therapist empathy was negatively correlated with session 6 client-rated progress. furthermore, both session 2 therapist empathy and acceptance were positively associated with session 6 therapist-rated progress, thereby providing some support for the therapeutic role of these two therapist variables as postulated by person-centred theory.     

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.     

Therapeutic action in psychoanalytic therapy with toddlers and parents

Psychotherapy with toddlers and parents can focus on promoting attachment, facilitating development and improving interactions. Some techniques provide guidance to the parents, whereas others interpret to them their unconscious fantasies or ‘ghosts’ contributing to the child’s disorder. A recent paper introduced a psychoanalytically oriented technique, which emphasised the therapist’s interaction with the child in the presence of the parent(s). The child was addressed about his/her unconscious motivations in the session and the feelings towards the therapist. Also, the parent’s transference onto the therapist was seen as a vehicle that might further the therapeutic process and was accordingly addressed. The present paper analyses the therapeutic action in such treatments. Whereas work with the parents resembles that of ordinary psychodynamic therapy, therapeutic action is more difficult to conceptualise regarding the toddler, whose understanding of verbal interpretations and the therapist’s dialogues with the parent is more limited than that of an adult. However, a clinical vignette demonstrates a toddler’s precise and swift reactions to communications from mother or therapist. The paper investigates evidence from neuroscience and psychological research as to which communicative channels – beyond words – toddlers might perceive and comprehend. In addition, it is claimed that the countertransference is key to explaining how the therapist understands such communication.     

To be in touch

This study examined the constellation of interaction structures – repetitive patterns of interactions between patient and therapist over the course of treatment – that emerged in the psychodynamic therapy (PDT) of a child diagnosed with borderline personality disorder and treated by two doctoral student therapists. Identification of these interaction structures can inform therapists of what might be expected from patients with particular symptom or behaviour patterns and how interactions change over time. This study also examined each session’s adherence to three session prototypes: PDT, cognitive-behavioural therapy (CBT) and reflective functioning (RF) process. The Child Psychotherapy Q-Set (CPQ) is a 100-item instrument that assesses the processes within a single psychotherapy session. Items reflect a wide range of therapist attitudes and behaviours, patient attitudes and behaviours and interactions between therapist and patient. Experts used the CPQ to define PDT, CBT and RF process session prototypes. The results suggested that four distinct interaction structures could be identified and that their constellations differed between the two therapists and also differed over time within each treatment. Therapists were more structured and accommodating early on in their treatments and more interpretive later. Prototypical PDT process was more prominent in the sessions than RF process, which in turn was more prominent than CBT process. Unique therapeutic processes are at work in every dyad, despite holding the patient and theoretical orientation constant. An effective treatment in one dyad might not work in another due to therapist-specific and dyad-specific effects.     

Safety-signal therapy in agoraphobics: a preliminary test

It has been argued that persistent avoidance behaviour is strongly influenced by safety signals, and that agoraphobic avoidance behaviour is a clinical example of this influence. It was proposed that agoraphobic avoidance can be reduced by the judicious use of safety signals, and specifically, by training patients to travel towards rather than away from safety. A safety-signal technique in which the patient travelled towards the therapist at the most fear-inducing situations was compared with conventional therapist-assisted exposure. In the second part of the treatment programme, both groups of agoraphobics were given homework assignments. The safety-signal technique resulted in slightly better clinical gains than those achieved by therapist assisted exposure, but after these relatively brief programmes, the improvements in both groups were weak. Global clinical outcome was influenced by age, chronicity and long-term benzodiazepine use.     

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.     

Managed Care and Psychoanalytically-Oriented Psychotherapy

This paper compares the conceptual base of psychoanalytically-informed psychotherapy with that of managed care. It is proposed that each is rooted in a discrete and incompatible system of thought and professional culture-one in psychoanalysis and the other in business. Differences exist between these cultures in the meaning of time, therapeutic goal, and clinical role. Case material illustrates the impact of managed care culture on the development of transference in both patient and therapist. The transitional space of treatment is expanded to a five party object relational system-patient, therapist, case manager, insurance company, and employer-that manifests culture clash.     

Videotaping as a therapeutic tool in psychodynamic infant– parent therapy

This paper describes an infant–parent therapy technique that involves the videotaping of the sessions, with subsequent reviewing and discussion with the mother. The technique has been designed as a part of psychodynamic therapeutic work with infant–parent dyads. It is based on a concept of the centrality of maternal past and current experience and associated representations in the pathogenesis of the relational pathology. Videotape replay provides an accelerated access to early maternal memories and promotes enlightening awareness of the links between maternal past experience and present behaviors with her child, which can lead to insight and therapeutic change. The technique advances the development of the therapeutic alliance and thus facilitates successful use of other dyadic treatment modalities that can be used along with psychodynamic therapy. It lessens maternal feelings of being criticized by a therapist and, therefore, can be helpful when the maternal ability to develop a trusting relationship with a therapist is of particular concern. Pertinent theoretical and practical issues are discussed. The method is illustrated by excerpts from therapeutic work with a six‐month‐old boy and his mother. © 2000 Michigan Association for Infant Mental Health.     

Network therapy for addiction: bringing family and peer support into office practice

Network therapy was developed as a specialized type of combined individual and group therapy to ensure greater success in the office-based treatment of addicted patients by using both psychodynamic and cognitive-behavioral approaches to individual therapy while engaging the patient in a group support network composed of family members and peers. This article outlines the role of group cohesiveness as a vehicle for engaging patients in this treatment; the patient's family and peers are used as a therapeutic network, joining the patient and therapist at intervals in therapy sessions. This network is managed by the therapist to provide cohesiveness and support, to undermine denial, and to promote compliance with treatment. The author presents applications of the network technique designed to sustain abstinence and describes means of stabilizing the patient's involvement. Some specific techniques discussed include ambulatory detoxification, disulfiram and naltrexone administration, relapse prevention, and contingency contracting. Also discussed are recent research on the use of psychiatric residents and counselors for treatment, and use of the Internet in dissemination.     

Voice of a hidden minority: Identification and countertransference in the cross-cultural working alliance

This paper has expanded the psychoanalytical definition of the working alliance to include the influence of culture. The cross-cultural working alliance is a therapeutic dyad that incorporates a psychotherapist and a patient of dissimilar backgrounds. Each participant enters the alliance with cultural introjects--values, attitudes, and ways of behaving that stem from ethnocultural roots. These introjects influence the intrapsychic world, shape the conscious worldview, and the perception of life experience. The influence of cultural predispositions on the psychopathologies of the patients was prominent in two case examples: a black West Indian male and a Korean-American male. The therapist also brought cultural predispositions to her work. A constructive countertransference phenomenon occurred in the working alliance that had a direct connection to its cross-cultural nature. This phenomenon is called associative identification--the conscious identification of therapist with the ego experience of patient. With the use of the associative identification, the therapist uncovered parallel memories that promoted theoretical understanding and informed therapeutic technique. Just as anthropologists claim that cultures share universal institutional patterns, it is proposed that universal cultural conflicts may also be observed in the cross-cultural working alliance. The analyst and patients in this study had two culture-conflicts in common: the longing to be seen, and the pull for disidentification. It is concluded that associative identification enriched the reparative quality of treatment, and encouraged the integration of isolated, split-off parts of the self.     

TOCRS—The therapy-oriented computer record system

A computerized system has been developed to provide treatment records for patients in the Duke Psychiatric Outpatient Clinic. Demographic, diagnostic, and therapeutic data are incorporated into a concise summary provided to the therapist for each patient visit. Variables were carefully chosen to capture essential therapeutic information while minimizing the burden of data entry on the therapist. Suggestions by the users have led to a number of modifications in the system, including the addition of special data-keeping functions for therapy groups and record generations of summary reports for clinicians and administrators. Essential information is gathered in a format well suited to analysis by standard computerized statistical techniques. Record keeping, in this fashion, provides an information base that describes the process of psychiatric treatment.     

Passt oder passt nicht?

Differential indication in psychotherapy should be a process of decision making, that takes multiple factors into account, and not just the assignment of a particular disorder to the adequate therapeutic method. Unspecific characteristics of the patient, instead of disorder-specific features, as well as personality characteristics of the therapist having therapeutic relevance are important factors either. In this way decisions for an indication then turn into the crucial question of matching between patient and therapist. The receptivity of the patient is a central component. As a result of successful maching, the therapeutic relationship will improve which has a positive influence on the outcome of psychotherapy. According to the generic model of psychotherapy 4 levels of the decision-making process are defined. They serve as orientation for a differential indication taking into account both persons and methods. The realization of this indication model in in-patient treatment has some preconditions. Obligatory is the availability of a variety of therapists differing in therapeutic methods and personal characteristics. The mostly applied principles of matching decisions are listed in tabular form and illustrated by a case report.     

Clinical Mutual Attunement and the Development of Therapeutic Process: A Preliminary Study

Despite the identification of many factors that play a central role in the development of the psychotherapy process, there is still a lack of evidence about the basic relational mechanisms that pave the way to its working. In this pilot study, we focus on nonverbal microprocessual attunement as the basic mechanism grounding the displacing of discrete factors in shaping the clinical process. Two single sessions of two short-term psychodynamic treatments, selected respectively from a good- and a poor-outcome treatment, have been coded in terms of patient and therapist speech rate, coordination in ruptures, resolution of the therapeutic alliance, and patient's displayed thinking processes. Two dynamic structural equation models focusing on clinical attunement as a factor able to activate the interplay of the assessed clinical dimensions have been theoretically designed and tested in both cases. The driven theoretical structural equation models fit the data, suggesting a different role of nonverbal attunement as a moderating factor. The obtained results are consistent with the hypothesis claiming that a good-outcome psychotherapy session is characterized by a mechanism of clinical attunement that enforces the therapist–patient relationship and promotes the integration of formal thinking processes that affect emotional and cognitive domains.     

Love in the therapeutic alliance

Volumes have been written about the patient's love for the therapist, but there has been relatively little discussion of the therapist's love for the patient. In an attempt to create a theoretical and technical space for discussing the appropriateness and role of love in the therapeutic relationship, a revised concept of the therapeutic alliance is applied to provide technical guidelines and understanding of two kinds of love between patient and therapist, corresponding to two systems of self-esteem regulation: an open, reality-oriented system and a closed, sadomasochistic system organized according to omnipotent beliefs. Examples of the role of love through the phases of treatment illustrate the interrelationship of love and the accomplishment of therapeutic alliance tasks.     

Case presentation: Jean

This symposium was devoted to the consideration of Dr. Mary Libbey's treatment of a 22-year-old woman. The unfolding of the analysand's symbiotic attachment to her mother, the devastating sequelae of her having been the stable center of a pathological family that devoted itself to the care of a severely handicapped sibling, and her immersion in unresolved mourning form the center of this richly detailed and carefully reported case study. In addition, four verbatim sessions are reported, one from each year of the first two years of treatment, and two from the third year of treatment. Dr. Epstein's discussion, praising Dr. Libbey's therapeutic skill, makes note of the issues in the patient's family of origin that served to prepare her to feel endangered in the treatment. Dr. Epstein's view is that the analyst has created an analytic situation that, because it is minimally impinging, allows the patient to become increasingly aware of her unmet needs in a way that is tolerable and minimally "destabilizing to the symbiotically based organization of her internal self and object world." In the climate of safety created in the treatment, the patient can begin to complete the work of mourning for her sister, friend, and aunt, a process of mourning that would be impossible in the context of her nuclear family, centered as it is on a mother who cannot tolerate separation. Limit-setting in the treatment is seen to be reassuring to the patient, facilitating as it does the analyst's commitment to maintaining the integrity of the analytic situation. Dr. Schafer's discussion, while in agreement with Dr. Epstein in recognizing the excellence of the presentation and the sensitivity and hard work that had gone into both the treatment and the clinical presentation, included some specific and focused observations about the transference and countertransference situations prevailing in this treatment and also some suggestions for creating a more consistently safe analytic atmosphere for this particular patient and others like her. Dr. Schafer proposes that the therapist acknowledge to herself and accept as well as possible the inevitable feeling of helplessness such patients provoke. In a more concrete vein, he advocates talking in the first person declarative as much as possible, preferring "I don't understand" to the more standard "What do you mean?" or "Why?" The therapist is encouraged to eschew interpreting what the patient says about the therapeutic relationship for a long time, and, further, he suggests not quickly connecting or easily reducing the therapeutic relationship to childhood prototypes.(ABSTRACT TRUNCATED AT 400 WORDS)