Self-Disclosure and the Therapeutic Frame: Concerns for Novice Practitioners

Under the influence of the intersubjective or relational perspective, guidelines for establishing the therapeutic frame in psychoanalysis and psychoanalytic psychotherapy are undergoing modification. Therapeutic interventions such as disclosing subjective reactions have a sound theoretical basis, but they must be executed judiciously within a context of general neutrality, anonymity, and abstinence. Novice practitioners ought not attempt the more difficult relational interventions until they have acquired experience and security in the basic tenets of psychoanalytic practice, including how to maintain the traditional therapeutic frame. Inexperience in knowing when and under what circumstances to attempt self-disclosure of therapist affect, and insecurity in examining one's countertransference, have the potential to exacerbate enactments and entanglements for beginning therapists, as is illustrated in a case example.     

On teaching psychoanalysis

Teaching psychoanalysis is no less an art than is the practice of psychoanalysis. As is true of the analytic experience, teaching psychoanalysis involves an effort to create clearances in which fresh forms of thinking and dreaming may emerge, with regard to both psychoanalytic theory and clinical practice. Drawing on his experience of leading two ongoing psychoanalytic seminars, each in its 25th year, the author offers observations concerning (1) teaching analytic texts by reading them aloud, line by line, in the seminar setting, with a focus on how the writer is thinking/writing and on how the reader is altered by the experience of reading; (2) treating clinical case presentations as experiences in collective dreaming in which the seminar members make use of their own waking dreaming to assist the presenter in dreaming aspects of his experience with the patient that the analytic pair has not previously been able to dream; (3) reading poetry and fi ction as a way of enhancing the capacity of the seminar members to be aware of and alive to the effects created by the patient's and the analyst's use of language; and (4) learning to overcome what one thought one knew about conducting analytic work, i.e. learning to forget what one has learned.     

Clinical commentary by David Trevatt,Clinical Manager of ‘Hear and Now’ Adolescent Counselling Service,Redbridge and Manager of Open Door's Parenting Teenagers Project,Haringey

Leading the charge to link intervention research with clinical practice is the development of process research, which involves a detailed analysis of specific therapeutic processes over the course of treatment. The delineation of interaction structures – repetitive patterns of interactions between patient and therapist over the course of treatment – can inform therapists of what may be expected from patients with particular patterns of symptoms or behaviours in their clinical practice and how interactions change over time. Using the Child Psychotherapy Q-Set, this study aims to compare the different interaction structures that emerged in the two-year psychotherapy of a six-year-old child conducted, for one year each, by two doctoral-student therapists in a university-based community mental health clinic. The study allows for exploration of the independent role of the therapist in the psychodynamic therapy of a child diagnosed with Asperger's disorder. The results suggest that four distinct interaction structures between child and therapist could be identified in this psychotherapy and that the interaction structures differed between the two therapists and also differed over time within each treatment. The implications of these findings for training and clinical practice are discussed.     

Four Dimensions of Envy: Strategies for Managing Its Manifestations in Psychotherapy

Envy is not an amorphous feeling and can be seen as consisting of four distinct dimensions, labeled identification, confrontive, redirecting, and medea. Just as we have to be aware of the traditional stages of psychosexual and psychosocial stages of development, we need to be alert as to what dimension of envy the patient may be experiencing at any given moment in psychotherapy. When these dimensions manifest themselves in therapy we find that each of them requires a different strategy by the therapist. Each dimension has its unique features and what is successful at one stage of treatment may be disastrous at another. If the therapist does not intervene at the beginning stages to prevent envy from increasing in intensity, there is a danger that the patient can slide into a stage in which effective therapy may be doomed.     

Toward engaging the difficult patient

The difficult patient is here described as the one who does not readily accept the usual definitions of the treatment relationship and who tends to get the therapist to be overly-engaged in the therapeutic process. The therapist must be clear not only about his own characterological issues and counter-transference predispositions, but also about the unique propensity of these patients for the enactment of conflicts. While empathy is the sine qua non of our therapeutic work, the need to set limits and to address hostility should not be underestimated if these patients are to be engaged in any meaningful psychotherapy. To maintain an empathic perspective, the therapist must appreciate the purposefulness of the patient's defensive characterological behavior and that it cannot simply be dismissed as mere pathology. Such a perspective may help the therapist to better respond to the patient's behavior as a communication about his sense of self and his concerns about relatedness. This will facilitate the engagement process.     

THE PSYCHOANALYST OF THE FUTURE: WISE ENOUGH TO DARE TO BE MAD AT TIMES3

What sort of patients do we have in psychoanalysis now, at the beginning of the third millennium, and what sort will we have in the future? In the author's clinical experience, the patients who are currently seeking help from the psychoanalyst use primitive defence mechanisms alongside neurotic ones. Most of them do not explicitly request psychoanalytic treatment, but this does not mean that they would not want it if they knew what it was. She argues that is the psychoanalyst's task to identify the latent request behind the ‘non‐request’. To conduct a psychoanalysis with such patients, the psychoanalyst has to identify and interpret both primitive and neurotic psychic mechanisms; moreover, he has to use not only language that speaks to patients but also language that ‘touches’ them, because these patients are difficult to reach through verbal symbolism. This implies that the psychoanalyst must be attentive to the bodily manifestations and bodily phantasies accompanying his countertransference feelings. The author shows through clinical examples what she means by ‘language that can touch patients’. The psychoanalyst gradually builds up this language while, at the same time, daring to discover in himself his own mad aspects and giving himself enough psychical freedom to accept them.     

Pete the diesel: Psychotherapy with a severely disturbed five-year-old boy

The psychic significance of the figure of the grandmother in psychodynamic psychotherapy has received scant attention. This paper develops the concept of the ‘grandmaternal transference’ in parent–infant psychotherapy and explores its identification, its possible functions and its therapeutic significance. The grandmaternal transference has special relevance to parent–infant psychotherapy since the grandmother often represents both the mother’s mother and the child’s grandmother and offers a unique third position between mother and child. Three clinical vignettes illustrate how the grandmaternal transference may operate in this third position. In the first vignette, the therapist becomes in the transference a containing grandmother thereby facilitating maternal containment. In the second case, the therapist may be experienced as a differentiating grandmother able to help mother and infant with separation and individuation. In the third one, the therapist is transferentially experienced as a paternal grandmother who acts as a pseudo-father able to embody the paternal function. In each of these positions, the transference and countertransference – whether positive or negative – require that the therapist responds to rather than enacts the grandmaternal role. The three configurations of the grandmaternal transference have different clinical manifestations and offer different therapeutic ports of entry.     

ON THE THERAPIST'S YEARNING FOR INTIMACY

From the beginning of clinical psychoanalysis, analysts have been at risk of succumbing to yearnings for intimacy and contact that are stirred up by the heat of the analytic encounter. Recently, as theoretical developments have encouraged us to create moments of meeting (Stern et al. 1998) and have urged us to tolerate the feelings stimulated by enactments, these risks have increased. The author points out that foregoing the realization of this yearning within the analytic relationship and the resultant mourning for the loss of a fantasy or illusion carries a heavy personal price tag for the therapist.     

Heinz Kohut and Virginia Satir: Strange bedfellows?

Both Heinz Kohut, the psychoanalyst, and Virginia Satir, the family therapist, are products of the humanistic influence in psychology that developed after World War II. Both have had an important influence on the practice of psychotherapy. Kohut expanded the scope of psychoanalysis so that more different kinds of people could be treated by psychoanalysis than had been possible heretofore, while Satir taught a whole generation of therapists what it means to be experience-near to their clients. This paper deals with some of the similarities and differences in their work.This paper was prepared at the invitation of John Banmen and Virginia Satir for inclusion in their forthcoming book entitledApplications of Virginia Satir's Theories and Practice of Family Therapy and was submitted to this journal with their courteous agreement.     

Editorial

Abstract

This paper will examine the current crisis in psychoanalysis in terms of the profession's decline, the apparent lack of patients, the ongoing debate over what constitutes psychoanalysis versus other therapies, and the lack of clinical focus in those debates. The concept of analytic contact will be introduced, and clinical material is used to showcase this concept as a bridge from the circular political debates to a more meaningful examination of what is psychoanalytic. In addition, case material will explore how patients tend to fight off the establishment of analytic contact in favor of safer, less threatening modes of relating. The author suggests that most patients fight off analytic contact and try to shift the treatment into something less analytic. It is up to the analyst to detect this, interpret it, and notice any countertransference collusion that may occur. Although the state of psychoanalysis as a profession is less than stellar in the eyes of the public, and the profession is apt to sabotage itself with endless debates about what constitutes true analytic work, the end is not necessary near. This paper proposes analytic contact to be the more useful focus of research and productive area of clinical exploration. If the decline of our field is to turn around, it will be on the clinical battlefront, not in terms of the theorizing among disagreeing groups of territorial analysts afraid of losing their political high-ground. The concept of analytic contact assumes that a deep exploration of intrapsychic phenomena, conflicts, and defenses, all within the realm of the transference, is the best clinical method of helping the mentally troubled individual. This genuine chance of change is best administered by a trained psychoanalyst. This simple idea is something the profession has contaminated with its often pointless arguments over frequency, analyzability, couch, and so forth. The clinical material will show that what happens in the room between analyst and patient is what best defines the true psychoanalytic treatment.     

Of Innocence and Experience: Commentary on Paper by Stuart A. Pizer

In providing the background to a pivotal session, Stuart Pizer reveals his clinical work as an unsupervised neophyte, prior to his own analysis and analytic training. These early therapeutic efforts were flawed, leaving Pizer at times “grimacing with mortification 26 years after the fact.” But they were also extraordinarily helpful to the patient. Schaffer discusses the challenge of supervising similarly talented beginners: how does one teach psychoanalysis without desiccating a treatment? How does one teach a relational approach, with no “basic model” and few rules, to a beginning analyst infused with an unformulated, yet often passionate, sense of what is “curative”? Pizer recognizes that were he to meet the same patient today, he would not conduct the same treatment. Now trained and analyzed, not to mention more cautious and “worldweary,” Pizer would not do what he did then. But what if he were the supervisor then? Schaffer concludes her discussion by asking Pizer how he, now a seasoned analyst, would supervise his early therapist self.     

The Problem of Thinking in Black and White: Race in the South African Clinical Dyad

Race, as it presents itself within the clinical dyad as an aspect of the relationship between therapist and patient, has scarcely been written about from an experience-near perspective within the South African context. This paper focuses on the difficulty of speaking and writing about race. It contends that race as a construct and as an aspect of subjectivity has the potential to interrupt the therapist’s capacity to think, in Bionian terms, and to prevent entry into the reverie that is crucial to the creation of an analytic third. Written through a relational psychoanalytic lens and drawing on the concepts of the normative unconscious and the anti-analytic third, the paper refers to clinical vignettes to illustrate the collapse in thinking and the progression to beginning to think, anew, about the race-nuanced, intersubjective space between patient and therapist.     

SPONTANEOUS “CURES”: NORMAN REIDER'S FORGOTTEN PAPER,PART II

Part I of this paper combined an introduction to Norman Reider's original 1955 paper with a republication of the paper itself. Part II is a discussion of the complexities of a comparison of past and present psychoanalytic literature. The concept of enactment is proposed as one of many possible alternative views in considering Reider's notion of spontaneous “cures.” A careful consideration of these spontaneous cures within the ordinary ups and downs of any psychoanalytic treatment sheds important light on our continuing confusion about how we define the term cure, and therefore about the nature of change during psychoanalytic treatment. This alternative perspective is only one of many plausible ones for present‐day readers. The purpose of this republication is not to propose an explanation for “what really happened” with Reider and his patients; rather, it is to reconsider the fallacy of evaluating his paper outside its historical context and thereby failing to appreciate his courage in presenting what at the time were radical views. Questions about the complexity and confusion regarding cure and change require reexamination of the neglect of epistemology on the part of psychoanalysis in prolonging the confusion about distinguishing psychotherapy and psychoanalysis.     

The patient's part in analytic process: the influence of the analyst's expectations.

The psychoanalyst's expectations of the patient are complex and crucial to the work of analysis. These expectations, operating at a level generally outside the consciousness of patient and analyst, are part of the "microstructure" of analysis, the interactional give-and-take that brings about change. The view taken here is that analytic process is necessarily interactive, as well as intrapsychic. In addition to transference-countertransference motivations, both parties to an analysis operate in a social context that prescribes a range of desired and undesired behavior. The analyst brings to the interaction professional analytic attitudes about how to listen and act, and a set of expectations of the patient. These attitudes and expectations modulate subjective reactions to the patient's transferentially driven actions, and influence the expression of countertransference. The mutative process of psychoanalysis involves the action of these attitudes and expectations on the patient, both in ways specific to individuals and in more general ways. Such expectations lie behind analytic tactics and, though not often written of, are part of the oral tradition of psychoanalysis. Here the expected patient role is described in terms of five bipolar continua: (1) reporting and editing; (2) transferring and containing; (3) thinking about oneself and thinking about the analyst; (4) regressing and listening/self-observing; (5) initiating trial action and mediating among inner states. The activity and thinking of the dyad move constantly along these continua. A clinical example from the beginning of an hour illustrates how these expectancies emerge in analytic work.     

Unerwünschte und schädliche Wirkungen von Psychotherapie

Unwanted effects or even damage due to psychotherapy are largely neglected issues within psychotherapy research as compared to other fields. On the other hand, it is reasonable to assume that unwanted effects of a treatment which intends to influence patients into a positive direction are very likely. The rate of negative effects of psychotherapy (the deterioration effect according to Bergin) is consistently estimated to be 10% of all cases and shows this same rate in a variety of studies. This review highlights side effects of psychotherapy both on the part of the patients and of the therapists. It reports unwanted effects related to different psychotherapeutic methods, i.e. psychoanalysis, cognitive behaviour therapy, client-centered psychotherapy and – beyond these basic orientations – group psychotherapy. The paper also reports on negative effects of psychotherapy on an untreated partner. Finally, some proposals are given on how negative effects of psychotherapy could be diminished. The authors especially highlight the possibilities of changing the therapist, the treatment technique, or the theoretical treatment approach as a way to reduce negative effects.     

Mein Konzept der Supervision

The reflections on supervision presented in this paper were written against the background of a psychoanalytic training. The paper describes what – in the author's view – characterizes a patient in psychoanalytic psychotherapy, a psychoanalytic therapist, and a supervisor. In addition, the author reports on his personal experiences which he has made with supervision in the course of his activity as a psychoanalyst in the roles of supervised and supervisor. In this context, he presents some actual memories from supervisory experiences with M. Balint, H. Argelander and F. Morgenthaler.     

Monitoring the effects of adult psychotherapy in routine practice in Switzerland: A feasibility trial

Background: Several studies have been published on the effects of psychotherapy in routine practice. Complementing traditional views summarised as ‘dose‐effect models’, Stiles et al. put forward data consistent with the responsive regulation model underlining the importance of the client's active participant role in defining length of treatment. One may ask what level of change reached by a patient is considered to be the ‘good enough level’ (GEL) and if it is related to the duration of psychotherapy. Aims: The main objective of the present feasibility trial was to monitor the patient's session‐by‐session evolution using a self‐report questionnaire in order to define the GEL, i.e. the number of sessions necessary for the patient to reach significant change. Method: A total of N=13 patients undergoing psychotherapy in routine practice participated in the study, completing the Outcome Questionnaire – 45.2 (OQ‐45), which assesses the symptom level, interpersonal relationships and social role after every psychotherapy session. The data was analysed using multi‐level analyses (HLMs). Results: High feasibility of fine‐grained assessment of effects of psychotherapy in routine practice in Switzerland was shown; response rates being acceptable; however, detailed analysis of the GEL was not feasible within the short study time‐frame. Conclusions: Reflections on the political context of monitoring in the specific case of routine psychiatric practice in Switzerland are discussed.     

The Functional Analytic Psychotherapy Rating Scale: a Replication and Extension

Few theories of psychotherapy give direction to the therapist on a moment-to-moment level or make predictions about how specific therapist techniques change client behavior in session. Functional analytic psychotherapy (FAP, Kohlenberg and Tsai in Functional analytic psychotherapy: a guide for creating intense and curative therapeutic relationships. Plenum, New York 1991) provides this direction and prediction. Specifically, FAP claims that client problem behaviors will be displayed in the therapeutic relationship and that the therapist can improve client in-session behavior through differential, contingent responding. Further, it is assumed that these improvements in session can be generalized to out of session relationships. The FAP rating scale (FAPRS) was developed for the purpose of coding in-session client and therapist behaviors in an effort to test FAP’s purported mechanism of change. The current study seeks to replicate and extend initial FAPRS findings (Callaghan et al. in J Contemp Psychother 33:321–339, 2003) regarding mechanism of change and to address transportability. FAPRS coding data from a single successful case of an individual diagnosed with Borderline Personality Disorder and treated with FAP is presented. Results indicate that the FAPRS system is transportable and are generally supportive of the claim that therapist contingent responding leads to client improvement.     

‘Critical psychotherapy,’ ‘postpsychotherapy,’ and the cult of technicism

This paper about the terms ‘critical psychotherapy’ and ‘postpsychotherapy’ argues that the terms ‘critical psychology,’ ‘critical psychiatry,’ and ‘postpsychiatry’ are already in use, and we can see the new terms – ‘critical psychotherapy’ and ‘postpsychotherapy’ – as additions to this already existing family of terms. However, this paper also argues that what is of most importance is not the case for using these new terms, but the tendencies and features these terms might be taken to refer to. The paper begins with an experience the author had while working as a counsellor some years ago. The terms listed above are explored, as are the roots of ‘critical psychotherapy’ in psychoanalysis, before providing an example of how a philosopher’s work might be relevant to psychotherapists.     

Not starting psychotherapy is more often initiated by the therapist than the patient

The phenomenon of not starting psychotherapy is seldom investigated. The present study of psychotherapy in the Swedish mental health services differentiates between patients applying for and being offered psychotherapy but choosing not to start (n = 69), patients recommended to receive no treatment, another type of treatment or treatment at another clinic (n = 133), and therapy starters (n = 1294). After the initial assessment, nearly twice as many patients did not start based on the therapist’s decision than on the patient’s. Cases of not starting psychotherapy decided by the therapist were more frequent among patients whose occupational status was less stable, presented a danger to others, had lower levels of initial therapeutic alliance, and by therapists with lower levels of psychotherapy training and those at less structured and more unstable clinics. Patients choosing not to start therapy had lower levels of mental ill-health than both starters and therapist-initiated nonstarters. The most frequently presented reason for a patient-initiated decision to not start therapy was “patient wished another treatment or therapist,” whereas the most common therapist-initiated reason was “recommended or referred to another treatment or clinic”.