Working with psychosis Part 4: Therapy online – ending by email

This is the fourth and concluding paper from a series about psychotherapy with a man suffering from a psychotic illness. The paper describes the ending of the therapy which was precipitated by my decision to leave the country. News of ending was extremely disturbing for my client and stirred fears that he would again break down and need re-admission to hospital. Six weeks before the ending he stopped attending but continued to stay in contact by email. I decided to reply to his emails during the session times, and we developed what he came to call his ‘email therapy’. This online technology provided a means for my client and me to separate, to find a third perspective and to begin to mourn this ending without him losing his mind and breaking down. Following James Fisher's ideas about ‘mourning in the presence of the loved object’ I understand aspects of this email ending as enabling a relinquishing of projective identification used to possess and control, a recognition of the freedom of the other and of the need to mourn omnipotence. I discuss some of the problems presented by premature ending with a vulnerable client – problems which can be seen in my difficulty of mourning and working through the ending reflected in the long time it has taken to finish writing this paper.     

Client concealment and self-presentation in therapy: comment on Kelly (2000)

The authors disagree with A. E. Kelly's (2000) conclusions that clients conceal things from therapists primarily for self-presentational reasons and that client concealment is positively related to positive therapy process and outcome. They also disagree with A. E. Kelly regarding the implications of self-presentation theory for therapy. Their review of the research suggests that clients do not conceal much from therapists, that what they do conceal involves many different kinds of information hidden for many different reasons, that therapists have wide variability in being able to detect hidden client material, and that the relationship of client concealment and therapist awareness of client concealment with therapy process and outcome is not clear. Finally, the authors discuss their views about implications of client concealment and self-presentation for therapy.     

Commentary: is collaboration a viable target for family therapists?

It is hoped that this commentary might serve to begin a discussion regarding collaboration, what is meant by it and whether it is a worthy goal for family therapists. I present the varying and sometimes contradictory meanings of the word, ‘collaboration’, as it is used in the therapy literature. Many of these meanings incorrectly imply an equality of the therapist–client relationship that only obscures the power differential that exists in the therapeutic relationship. A linguistic analysis of the primary meaning of ‘collaboration’ as ‘work with’ is presented. It is argued that equality between therapist and client cannot be achieved and need not be strived for. Therapists are encouraged to focus on the quality rather than the equality of their relationships.     

The complaining client and the troubled therapist: a discursive investigation of family therapy

In this paper I examine two important issues for family therapy research. I attend to the concept of complaints, highlighting the conversational structure they take in a family therapy setting. I do this by outlining how clients construct their complaints and examining how the family therapist receives them. Data is taken from a corpus containing four different families and two different therapists, and is subjected to discursive analysis in order to provide a rich analysis of not just what is happening in the talk but how it is happening. I conclude that complaints are not received as useful to the therapeutic process, despite their constructed importance to the client, and therefore there are wider implications for therapy and professionals more generally, particularly implications for multi-agency communication.     

Contemporary MFT Models’ Alignment with Relational Common Factors

Common factors theorists believe that therapy is effective, not only because of model specific elements, but also, because of common factors that cut across various treatment models. Common factors include extra-therapeutic factors such as treatment setting, therapeutic alliance, therapist variables and client variables. Common factors researchers have proposed a set of relational common factors that are unique to the practice of marriage and family therapy, including the ability to conceptualize difficulties relationally and the ability to disrupt dysfunctional relationship patterns. In this paper, I analyze and compare relational common factors in three contemporary models: narrative therapy, solution-focused therapy and cognitive-behavioral therapy. Finally, I discuss significant implications for theorizing, training and supervision.     

Some Hypotheses about Hesitations and their Nonverbal Expression in Family Therapy Practice

When people seek therapy they have stories to tell. In the course of the therapeutic conversation the clients continually make selections about what they want to tell, and what they want to keep silent. In this article the author focuses on the border zone between the said and the not-yet-said, and proposes three hypotheses about the client's hesitations about speaking in the family therapy session. In these hypotheses 'hesitation' is used as a metaphor to give meaning to some nonverbal utterances of clients in such a way that space is opened up in a respectful way for as-yet untold stories. I suggest that it is fruitful to think of certain nonverbal utterances of the clients as hesitations to proceed with the conversation, and to use these nonverbal utterances, in the line of Tom Andersen's thinking (1995), as a starting point for a respectful dialogue with the family about the good reasons they might have not to speak. Not only can this open up space for as-yet unspoken stories, it can also help the therapist to establish a collaborative therapeutic relationship with the family. These ideas are illustrated with several case studies.     

‘I never talked about,ever’: A comprehensive process analysis of a significant client disclosure event in therapy

Aims: The present study was intended to examine how a particular client disclosure came about and what made it important to the client. Method: A client‐identified significant therapy event involving disclosure of childhood abuse was analysed using Comprehensive Process Analysis (CPA), a qualitative interpretive method for examining the process, effects and context of significant events in therapy. Results: The analysis identified therapist invitation and client universalisation as the key elements of the disclosure event. The context analysis showed how the event linked to the client's symbolisation of her fear earlier in the session and in the previous session. The client gained insight into how the earlier abuse had affected her life, linking it to the victimisation that was her primary reason for seeking therapy, and to her relationship with her mother. The therapist facilitated the event by following up the client's hints, trusting the strength of the alliance, and staying close to the client's frame of reference. Conclusion: The findings suggest that the initial significance of an invited disclosure event may diminish for a client over the course of therapy.     

Reflections on a psychiatric placement

Abstract

During a seminar last year, I was teaching a group of counselling students on the subject of depression. One of the students asked me what I thought of referring a depressed client to a psychiatrist. I replied that in my opinion it was better to keep a person out of the psychiatric services as much as possible. This was an opinion I began to reconsider over the course of a six-month psychiatric placement, undertaken as part of an analytic psychotherapy training.     

NEED,GREED AND ENVY IN ANOREXIA NERVOSA AND THE CHALLENGE THEY PRESENT

For as long as man has been on this earth, envy and greed have performed a duet of destruction. Indeed, these terrifyingly complimentary emotions have been at the root of the worlds' great conflicts and can be seen featuring as a point of origin in what are euphemistically referred to as ‘crimes of passion’. In biblical accounts, both were sighted amongst the seven deadly sins. An impressively awesome curriculum vitae indeed.

In this paper I should like to explore the role of envy and greed in the formation of anorexia nervosa, where it would appear that the destructive nature of this powerful duo have been turned inwards against the body itself. Analytical theorists make much of the difficulties evoked by the Oedipal situation. These particular theories are explored at length and applied to anorexia nervosa. In attempting to understand how this painful stage of development impacts upon this client group, the difficulties posed and the coping strategies employed to alleviate them are both examined.

A further avenue discussed is the particular challenge anorexia nervosa sufferers pose to those of us who would seek to engage them in therapy. Anorectic difficulties in engaging and accepting therapy are explored and understanding is sought as to how we might begin to make progress with this most intractable of illnesses. I would like to illustrate these issues by utilizing my experiences of working clinically with a client suffering from an enduring eating disorder.     

Violinists Run Amuck in South Dakota: Screen Doors Down in the Badlands!

Abstract

This paper proposes and defends an account of what it is to act for reasons. In the first part, I will discuss the desire-belief and the deliberative model of acting for reasons. I will argue that we can avoid the weaknesses and retain the strengths of both views, if we pursue an alternative according to which acting for reasons involves taking something as a reason. In the main part, I will develop an account of what it is to take something as a reason for action. On the basis of this, I will then offer a new account of what it is to act for reasons.     

Family therapy and the notion of accountability: With reference to trends in individual psychotherapy

Family therapy both overseas and within Australia has seen a rapid rise in popularity and general acceptance as an important therapeutic intervention. Along with the growth in interest, however, has come an increased demand for accountability. The foundation stone for the accountability issue surrounds the questions of therapy efficacy. How effective is family therapy, and, indeed, if it is effective, what are the active elements or ingredients which facilitate positive client change? Three groups, in particular, have vested interests in questions relating to the effectiveness of family therapy: researchers, therapists, and consumers. Although both researchers and therapists, for a variety of reasons, have been concerned with the effectiveness of treatment for some time, it has only been relatively recently that there has been a concerted push from various sections of the consumer group, including administrators, legislators, and policy makers. The consumer group is now providing pressure on professionals as to what we have done, and are doing, to demonstrate that family therapy really “works.”     

A third language in therapy: deconstructing sameness and difference

The paper draws on recent research and the first author’s personal story to show what happens when the language difference between therapist and client is brought to mutual awareness in the therapy room. Individual lived experiences of migrant psychotherapists and counsellors and the issues that arise in therapy practice when the practitioners use their second language as the means of communication with clients are explored. The notion of a third language – a dynamic communication system that is a result of developing a professional identity through a second language – is introduced. Unlike the psychoanalytic third, it is often conscious and may be used either defensively or purposefully as a concrete third point of reference in the intersubjective encounter. The paper explores how the concept of a ‘Third Language’ can be used as a tool to negotiate perceived sameness or difference in therapeutic encounters and to build a common language with a client, both literally and metaphorically. The study featured in the paper has implications for practice, theory and research.     

Importance of Therapist Use of Social Reinforcement with Parents as a Model for Parent-Child Relationships: An Example with Parent-Child Interaction Therapy

ABSTRACT

This paper focuses attention on the therapeutic relationship in parent-child therapy by using social reinforcement with parents and children as it relates to Parent-Child Interaction Therapy (PCIT). As in other therapy contexts, it is argued that having the therapist serve as a mediator of social reinforcement facilitates client change, After discussing different aspects of PCIT, we discuss the therapeutic relationship as viewed through other theoretical frameworks. This is followed by a discussion of the role of social reinforcement in the parent-child relationship. We then discuss at methodological and applied levels, the importance of therapist accuracy and consistency in the delivery of reinforcement as a means of changing the parent-child relationship. Next, this is followed by a discussion of the therapist-to-parent-to-child sequential chain of behaviors involved in PCIT. Finally, suggestions for future empirical studies are considered.     

Topic-focused analysis in a case of integrative psychotherapy with a father fearing his own anger

Even though evidence-based knowledge is considered the foundation of clinical practice, many clinicians question the clinical relevance of published research. Clinicians increasingly define themselves as having an integrative stance, in contrast to the tendency for most research to be based on clearly defined psychotherapies. Qualitative single case studies make it possible to generate knowledge about what actually occurs in integrative therapy. Topic change process analysis (TCPA) is used in the analysis of brief integrative therapy conducted by a very experienced psychotherapist drawing on a complex variety of therapeutic approaches. The client was a man in his late thirties, worrying about his strong anger, particularly related to one of his children. Analysis of topic areas, topic shifts, response patterns within topics and changes in perspective made it possible to identify key processes and key patterns of the therapy which resulted in a very positive outcome for the client. Implications of these findings for practice, and future research, are discussed.     

Containment,curiosity and consultation: an exploration of theory and process in individual systemic psychotherapy with an adult survivor of trauma

This paper describes an individual therapy from the author's private practice. On referral, the client came to therapy requesting help with her 8‐year‐old daughter. Within the assessment, a single episode of trauma was revealed. Further therapeutic conversations told of multiple memories of trauma. The main therapeutic work has now ended, the contract being left that the client can continue to request appointments if she wishes. I show how systemic therapy from Post Milan and Narrative models, including practices from other orientations, has been useful and name three key practices as being crucial to the work, containment, curiosity and consultation. I suggest parallel processes operating between myself and my client as well as between the therapy and consultation. Distinct phases in the therapy recovery are identified. The discussion will consider themes of containment, curiosity and consultation.     

Does Ontology Rest on a Mistake?: Andre Gallois

I discuss Steve Yablo's defence of Carnap's distinction between internal and external questions. In the first section I set out what I take that distinction, as Carnap draws it, to be, and spell out a central motivation Carnap has for invoking it. In the second section I endorse, and augment, Yablo's response to Quine's arguments against Carnap. In the third section I say why Carnap's application of the distinction between internal and external questions runs into trouble. In the fourth section I spell out what I take to be Yablo's version of Carnap. In the last I say why that version is especially vulnerable to the objection raised in the second.     

Book Reviews

Abstract

The aim of this paper is to identify what I take to be the main conceptual problem in Lewis’ semantics for counterfactuals when the Limit Assumption (LA) is not satisfied, what I call the Discrimination Problem (DP), and to present and discuss a modification of Lewis’ semantics that aims at solving DP. First, I outline Lewis’ semantics, highlighting the aspects that will be relevant for our discussion. Second, I present DP and discuss it with a heuristic example. Third, I present the new proposal and comment some formal consequences and the objections they give rise to. Fourth, I present an allegedly equivalent version of the proposal and discuss the difference between counterfactuals and strict conditionals. Finally, I defend that the two proposals are different and argue for the first one as the best way of capturing two intuitions that seem in conflict when the LA is not satisfied. I conclude with a dilemma: either the proposal here defended works or LA is inescapable. Thus, if the proposal doesn’t work, the paper must then be considered as an indirect defense of the Limit Assumption.     

Postmodern collaborative and person‐centred therapies: what would Carl Rogers say?

Among the most frequent comments and questions about my postmodern collaborative approach to therapy are ‘It sounds Rogerian’ and ‘Is it any different from Carl Rogers' client‐centred therapy?’‘Yes,’ I usually say, ‘there are similarities and differences.’ Here I overview the Collaborative and Rogerian approaches, highlight selected similarities and distinct differences, and comment on the relationship of each to family therapy as I see them.