Patterns and determinants of attitudes of psychiatric residents toward group therapy

The nature and origins of psychiatric residents' attitudes toward group psychotherapy were assessed by means of a semistructured interview. Subjects were 10 PGY-4 residents from five different residency training programs. Questions focused on subjects' perceptions of the possibilities and limitations of group therapy as a treatment modality, the efficacy and dangers of combined and conjoint treatment, the nature and extent of their training experiences in group approaches, the salient characteristics of their group therapy teachers and supervisors, and the attitudes of faculty about group psychotherapy that they were able to infer. Results suggest enormous variability of residents' attitudes. Hypotheses about the reasons for such variability are offered.     

Group psychotherapy with borderline patients: Contrasting remainers and dropouts

Borderline patients present major treatment difficulties in almost every treatment modality. The reason borderlines drop out or fail to benefit from therapy are obscure. Some findings points to the important factor of therapist and patient fit. In the present study, two therapy groups with borderline patients were followed for 20 months. In the study, the therapists were found to individualize the process and their interventions were found to be unevenly distributed among future remainers and dropouts especially during periods of group instability. The results were interpreted along with the Pygmalion hypothesis, that is, that the fit and the therapists' perceived trustworthiness were crucial factors for group psychotherapy outcome for borderline patients.     

Using parent-infant dyads as models for interpreting the parallel process

Studies indicate that parents replicate with the therapist the behaviors and perceptions they experience with their infants. During parent-infant therapy, the therapist may validate perceptions by comparing the parent's behaviors with verbal disclosures. A similar phenomenon occurs in psychotherapeutic supervision. Therapists in training tend to replicate with the supervisor the interactions of their patients, a phenomenon labeled parallel process.This paper suggests that parent-infant interaction may provide insight into the therapistpatient and therapist-supervisor relationships. Understanding the parallel process that occurs during parent-infant therapy may help the therapist explore the patient's perceptions and resolve conflict.     

In the belly of the beast: traumatic countertransference

The authors discuss their work together in a consultation process. One author led many groups that were created to facilitate recovery for persons directly impacted by the terrorist attacks on September 11, 2001; the other acted as consultant to the therapist/leader. The leader was a resident of New York City at the time of the attacks; the consultant lived in a distant Midwestern city and the two had never met prior to the work. They describe their experience of working together and the role of this collaboration in the lives of the leader and the groups. Well aware that little exists in the literature about groups led by leaders having experienced the same trauma as group members, the authors pay special attention to the countertransference that each underwent and raise questions about the effects of that on the group process.     

The Edge of Chaos: Enactment,Disruption, and Emergence in Group Psychotherapy

The author outlines his approach to the theory and practice of group psychotherapy. The emphasis is on therapy by the group rather than therapy in the group. The therapist's task is to help the group itself become the agent of change. The group is conceived as being composed of many multiple selves. The process of group psychotherapy unfolds through enactments that involve the whole group and the group therapist entering into the grip of repetitive and unmentalized self-states. These enactments are resolved when the group members, with the therapist's help and containment, can access alternative self-states that allow for new and unformulated experience to emerge. This dialectical movement between the rigid “familiar chaos” of enactment and the reflective and related working through is compared to the dynamic systems theory articulation of the tension between rigidity and chaos captured by Kauffman's notion that “life exists at the edge of chaos.” A group session is described that involves a painful enactment. It illustrates how the therapist allows the enactment to unfold by holding and containing intense affect and how the group members are helped to find their own meaning and new experience in interaction with each other.     

A test of psychotherapists' and nontherapists' recognition of correct and incorrect process in managing client resistance

Objective

Psychotherapist management of client resistance (i.e., opposition to change or the therapy process) has a significant impact on therapy outcomes. This study aimed at assessing psychotherapists' and nontherapists' abilities to recognise empirically supported correct and erroneous therapist responses to client resistance.

Method

Seventy-eight therapists and 111 nontherapists completed a rapidly administered novel skills test, Therapist Errors in Resistance Management (TERM), assessing recognition of correct and erroneous resistance management.

Results

Participants were, on average, less than half as accurate at recognising therapist errors (recognised below chance levels) compared with correct therapist responses to resistance (recognised above chance levels). Therapists outperformed nontherapists in accurate recognition of therapist responding. However, among the therapist group, greater clinical experience did not predict superior recognition of therapist errors.

Conclusion

These results indicate that therapists and nontherapists alike may have difficulty detecting erroneous therapist responses to resistance, tending to mistake empirically contraindicated directive responses for correct responding. This may reflect the difficult and unintuitive nature of correct resistance responding and may suggest a need for increased training in process acuity and resistance management in therapist education.     

Psychotherapists' dreams about their patients

Abstract This study examines therapists’ dreams about their patients from the Jungian and the relational perspectives. Few clinical and empirical references to this subject are to be found in the literature. In the present study 31 dreams were collected from 22 therapists. Dreams were collected using anonymous self‐report inventory. The research focused on three theoretical research questions: 1. What themes appear in the manifest content of therapists’ dreams about their patients? 2. What contributions are made by Jungian interpretation of therapists’ dreams about their patients? 3. To what extent are masochistic contents present in the manifest content of therapists’ dreams about their patients? The first question was addressed using categorical content analysis of a) themes common to different dreams and b) pre‐determined themes for all dreams. The third research question was addressed using Beck's (1967) ‘Masochistic Dream’ measure. Results: Among the themes common to different dreams were: therapist‐patient role reversal; therapist and/or patient attends and remains in meeting, departs/doesn’t depart; cancellation of therapy session; sexuality between therapist and patient; aggression; presence vs. absence; non‐verbal relationship and communication; time; driving vs. stopping. With regard to pre‐determined themes it was found that in 20 of the 31 dreams, the therapist had a negative experience and was characterized as vulnerable. Likewise it was found that 26 out of 31 dreams took place in either a) a street, a road, a route, a corridor; b) en route to somewhere; c) a therapy room and/or building; d) a house. With regard to the contribution of Jungian interpretations of the dreams it was found that 17 of the dreams had diagnostic and prognostic elements, 4 of which were initial dreams, 9 of them were compensatory dreams and in 14 it was found that the patient represents the shadow of the therapist. With regard to the third question it was found that 18 of the 31 dreams met Beck's (1967) criteria for masochistic dreams. The theoretical discussion examines the findings from a Jungian perspective, with an emphasis on also understanding the dream in terms of its expression of relational aspects of the therapist‐patient relationship. The findings affirm the presence of the ‘wounded healer’ archetypes in therapists’ dreams about their patients. The results of the study indicate that therapists’ dreams about their patients can be a valuable tool for deepening understanding of the therapeutic relationship and process.     

Sensory Deprivation: A Symposium Edited by Philip Solomon

In psychoanalytical psychotherapy interpretation is the main activity of the therapist. It is related to revealing the latent structure of meanings of phenomena. The phenomena of analytical therapy are presented as generated by the interaction of two structures: the therapeutic setting and the theoretical models of the therapist. The analytical group setting is contrasted with the individual setting through the elaboration of its central characteristic: the lack of intimacy. This is seen as generating specific regressive phenomena in groups which the therapist will attempt to interpret following an object relations theory. A discussion of interpretations in analytical group therapy focuses on three levels: the group itself, the interpersonal, and the intrapsychic. These are presented as complementary rather than mutually exclusive. Finally, the therapists' function in groups is discussed through the notion of the oscillatory nature of their participation, from a passive–receptive stance to an active–synthetic function which leads to the delivery of an interpretation.     

Psychoanalysis and the Education of the Child by Gerald H. J. Pearson

A conceptualization is presented which encourages a renewed exploration of the way in which psychiatric patients discuss their medications in the group therapy setting. It is suggested that process-oriented group therapiststend to harbor subtle prejudices which may inhibit examination of this material. If we listen to medication-related discourse more carefully, we find that patients disclose important information about hopes and fears about treatment, self-efficacy, attitudes about control and authority, and other sensitive or disowned parts of experience. The process of interactions about medicines often reveals interpersonal difficulties, particularly around intimacy. Suggestions for intervening more effectively with this type of material are presented. The importance of medication attributions in revealing curative fantasies is discussed.     

Situational countertransference

Situational Countertransference refers to those responses on the part of the therapist that are generated primarily by severe, though temporary, distresses in the therapist's personal life. It has been this writer's experience that many patients are quite attuned to the inner turmoil of their therapist, and that they will react to it in a variety of ways, which will be described. Moreover, a comparison of the level of functioning of two similar therapy groups over the course of nine months found that the group which had inadvertently learned the source of their therapist's distress functioned significantly better than the group which ostensibly knew nothing about it.     

When the therapist says goodbye

Therapist-initiated termination poses several unique problems for both the group and the therapist. This paper describes the termination process from the point of view of this therapist's experience in planning the termination of her group therapy practice. The reactions of other analysts to her decision to retire and the group processes and individual patient's reactions in this long-term psychoanalytic therapy group are described in detail. The author follows the group process and her own inner processes in the final six months of the group. The importance of the working through of the termination phase of therapy is supported by the experiences that were shared by the group and the therapist.     

A.G.P.A. News

Clinical observations regarding themes and roles that are characteristic of short-term, psychoanalytically oriented therapy groups for loss patients are presented. They reflect aspects of both the therapy and the patients. Themes refer to the content of a recurrent conflict in the group. They include trust, survivor guilt, mortality, and termination. Roles refer to a set of patient behaviors that represent a shared conflict. They include the apparition, monk, professor, professional nurturer, emotional conductor, and cruise director. Challenges that the themes and roles present to the therapist and clinical guidelines for addressing them are offered. Awareness of characteristic themes and roles and possible therapist responses are regarded as important parts of the preparation and training of therapists who plan to conduct short-term loss groups.     

Group Psychotherapy: A Behavioral Approach

Abstract

This clinical report highlights some of the processes arising in a therapy group of persons with persistent and chronic psychiatric illnesses as they cope with the stress of their long–standing therapist’s impending retirement. Members were initially disbelieving that the therapist would leave and were also concerned about their future care, particularly in terms of medications. Gradually they were more able to experience their feelings of loss and their genuine caring for the therapist and the group, using higher level defenses and increasing their ability to tolerate strong affects. They became increasingly able to demonstrate empathy, notably in their ability to consider the therapist’s emotions. The clinical material also illustrates the therapist’s personal involvement, countertransferences and expressions of concern.     

The Bulimia Workshop: A Unique Integration of Group Treatment Approaches

The time constraints of weekly group therapy and the slow evolution of group cohesion attenuate the direct confrontation that is essential with bulimic patients. Consequently, a three-phase, multidimensional group program was devised to accelerate the treatment process. Treatment begins with an intensive weekend workshop during which members formulate contracts for interrupting the binge–purge cycle and changing symptomatic behavior. During a follow-up session problems in fulfilling the contracts are dealt with and successes are reinforced, in the final phase, group members convene without their therapists to provide peer support, reevaluate contracts, and share feelings regarding treatment progress. The unique implications for treatment process and therapist interventions prompted by this new format are discussed, and preliminary research findings are highlighted.     

Introduction to Group-Analytic Psychotherapy by S. H. Foulkes

This article will explore special leader issues that emerge in psychodynamically oriented therapy groups with adult children of alcoholics. Particular focus will be on countertransference feelings that get stirred up in group leaders and techniques for dealing with some of these special dilemmas. Specific issues include (a) assumption of sameness between the therapist and the patient (the therapist assuming that he or she “understands” because of having also grown up in an alcoholic family); (b) the “will to restore,” which may be destructive when the therapist, whose own self-esteem is dependent on the patient's progress in therapy, forces a “rush to recovery” on the patient; (c) other personal issues in the life of the therapist that may also resonate with experiences of the patient; (d) “countertransference goodness and availability” as it affects therapists' abilities to set reasonable limits on their patients, as well as reasonable expectations for themselves; and (e) special issues regarding therapist transparency and self-disclosure.     

Kernberg's theories: Some clinical applications

Combined group and individual treatment by the same therapist is recommended for borderline and narcissistic patients. Modified psychoanalytic therapy that systematically focuses on aggressive drive derivatives and differentiates libidinal from aggressive components of self and object representations, and pregenital from genital condensed instinctual aims, is outlined. The group setting allows patients to observe and experience social and interpersonal behavior and indirectly to work through transference resistance and splitting. Innovative techniques focusing on the body, imagery dimensions, and serial role-playing are suggested. The complementary and reciprocal relationship between individual and group treatment focuses on discovery of the authentic self.     

Group Psychotherapy With Ego Impaired Children: The Significance of Peer Group Culture in the Evolution of a Holding Environment

In this paper, we will attempt to delineate the process by which peer group culture emerges and develops among groups of ego impaired children. The process of culture building in groups, as will be illustrated in a detailed case presentation, is critical for the child's development of skills for structuring and ordering the internal and external worlds. By definition, ego impaired children lack the ability to organize their internal experience. The challenge of group treatment with these children is to provide a situation in which their maladaptive efforts to organize volatile affects and impulses can be tolerated and structured. If they are provided with an adequate holding environment, the children learn to create cultural structures (i.e., therapeutic group culture), for the representation of salient aspects of their emotional lives creates the basis for internal organization. Their growing capacity to build integrating structures, at first collectively within the group, (Pfeifer and Weinstock-Savoy, 1984), which previously could only be provided by the therapist functioning as an auxiliary ego.     

Psychological Interpbetation by Leon H. Levy

Hispanics in the United States mainland underutilize mental health services and drop out of treatment sooner than dominant culture groups. One reason for this problem is that the sociocultural value orientation and expectations of the Hispanic patient are discordant with the values and expectations of the professional offering help. This paper focuses on the special problems resulting from the sociocultural differences between therapist and patient, and discusses why group therapy is uniquely suited to address these problems. It argues that group therapy offered by a leader with knowledge of the culture has an advantage over other forms of treatment in engaging Hispanic patients and in helping them to increase the effective use of mental health services. Issues of group formation, pregroup contracting, and the stages in the life of a Hispanic therapy group are also discussed.     

‘Learning from research’: Therapist perspectives on the benefits and challenges of participating in a longitudinal,systematic case‐study

Objectives: In psychotherapy research we have often neglected to examine the impact of research procedures on therapy process and outcome. Such information is extremely important in helping us evaluate the validity of our findings, increase relevance of research for practice, and choose appropriate methods for future projects. The aim of this paper is to share the experience of six person‐centered therapists, who participated in a longitudinal, systematic study, and present their reflections about the impact of research on therapy process, therapeutic engagement and professional development. Methods: The findings have emerged from semi‐structured interviews that took place after the first, sixth (middle) and last therapy session. In total 18 interviews were conducted. These data were part of a much larger research protocol that included a number of outcome and process measures. Results & Conclusions: The analysis of therapist narratives revealed important benefits for those participating in systematic case study research. The use of Brief Structured Recall methods and qualitative interviewing was an important factor in promoting therapist reflexivity and professional development. The importance of a strong research alliance and the active involvement of the client in the research process is discussed.