Therapeutic assessment case study: treatment of a woman diagnosed with metastatic cancer and attachment trauma

This article presents a Therapeutic Assessment (TA) case study of a woman recovering from 4 years of intense medical treatment for stage IV cancer. The inclusion and utility of using the Adult Attachment Projective Picture System (AAP) in the TA is highlighted. The client's attachment classification as unresolved helped identify that her current experiences with dissociation and problems restructuring her life following cancer remission were related to severe childhood sexual abuse, which she had suppressed for decades. The AAP also provided information regarding the unconscious defensive processes the client employed to cope with attachment distress and her inability to find comfort and support from others. These findings were instrumental in guiding the subsequent psychotherapy. The TA process, particularly the assessor-client relationship, facilitated an experience of containing her previously unintegrated and dysregulated affect. A single-case experiment using daily measurements suggested that participation in TA coincided with symptomatic improvements in multiple domains. These improvements were maintained during 4 months of biweekly psychotherapy after the completion of the TA. This case illustrates the applicability of the TA model in health care settings, demonstrates the usefulness of the AAP in the context of TA, and provides empirical support for the effectiveness of the TA model in initiating symptom improvement.     

Developmental aspects of trauma and traumatic aspects of development

In this paper I try to show that inherent in healthy development are emotional experiences that are the stuff of trauma. Failure to reintegrate these experiences means that they can serve as a resonating board for difficulties in later life, adding to their traumatic impact. Focusing on global changes that occur at the end of the first year, I exemplify these developments with an infant observation and show how a six-year-old boy's failure to integrate them contributed to his experiencing a normal life event as a trauma. I then offer clinical material from the analysis of a man to demonstrate how later life events resonated with early experience associated with this period. All are linked to a complex pattern of object relations I have come across clinically, whereby feelings of grief associated with an idealized object are split off from feelings of grievance against an object experienced as persecutory because of its perceived superior status.     

Disorganization and Individual Psychotherapy for Schizophrenia: A Case Report of Metacognitive Reflection and Insight Therapy

Despite being a characteristic symptom of schizophrenia, implications for therapy with persons experiencing prominent disorganization have received less attention in the psychotherapy literature than have other aspects of the disorder. As such, formal thought disorder may be viewed largely as a barrier to effective participation in therapy. In contrast, though, a range of writers from varied traditions have stressed that this feature of schizophrenia is meaningful and improved coherence of speech is an important and viable component of treatment and recovery. This paper suggests that an emergent integrative psychotherapy, metacognitive reflection and insight therapy (MERIT), may be well-suited for work with persons experiencing disorganization symptoms. A brief overview of MERIT is provided, followed by a case report of an 18-month course of therapy with a man with severely disorganized speech.     

Pragmatism, Pluralism, and Psychotherapy Relationships: An Interview with John C. Norcross, Ph.D.

John C. Norcross has made significant contributions in the areas of the transtheoretical model of change, psychotherapy integration, and empirically supported psychotherapy relationships. This interview explores the contributions of pragmatic philosophy and his personal upbringing to his work as a psychotherapy researcher and practitioner. Dr. Norcross discusses the status of the psychotherapy integration movement, the work of the Task Force on Empirically Supported Psychotherapy Relationships, and future trends in psychotherapy over the next 25 years. He emphasizes the importance of a methodological rigor that recognizes the unique characteristics of the psychotherapy relationship. He describes his current interest in the psychotherapy of psychotherapists, illustrating it with his personal challenges in balancing work and home.     

The Adult Attachment Projective Picture System: integrating attachment into clinical assessment

This article summarizes the development and validation of the Adult Attachment Projective System (AAP), a measure we developed from the Bowlby-Ainsworth developmental tradition to assess adult attachment status. The AAP has demonstrated excellent concurrent validity with the Adult Attachment Interview (George, Kaplan, & Main, 1984/1985/1996; Main & Goldwyn, 1985-1994; Main, Goldwyn, & Hesse, 2003), interjudge reliability, and test-retest reliability, with no effects of verbal intelligence or social desirability. The AAP coding and classification system and application in clinical and community samples are summarized. Finally, we introduce the 3 other articles that are part of this Special Section and discuss the use of the AAP in therapeutic assessment and treatment.     

Within or without: negotiating psychic space with an adolescent at risk of developing a narcissistic personality structure

This paper examines a 22-month once weekly psychotherapy with an adolescent young man. My patient was one of a group of adolescents who, due in part to excessive aggression, envy, anxiety or confusion, has chronically evaded the intimate and dependent psychic contact with others that is necessary for psychological development. In my view, this comes about through a combination of external factors and internal predisposition, with the quality of care received during infancy playing a crucial role. These adolescents appear to be developing narcissistic modes of being in the world which if allowed to persist into adulthood would be seen as deeply entrenched clinical psychopathology. Managing separation and loss is one of the central aspects of adolescence, but these young people tend to intrude or merge with others with such aggressive force that recognising difference between self and other becomes difficult. In psychotherapy, this often takes the form of the patient’s inability to tolerate experiencing the therapist as a separate person, and when knowledge of the therapist as separate impinges on their view, they frequently react in a variety of primitively destructive ways. This paper seeks to explore these central ideas through a detailed examination of psychotherapy with a young man in whom such struggles predominate.     

Using Narrative Theory and Self Psychology Within a Multigenerational Family Systems Perspective

This paper illustrates how a process of psychoanalytic psychotherapy can be enhanced and extehded by combining ideas from narrative theory and self psychology within a multigenerational family systems perspective. The illustration is based on a summary and discussion of a satisfactorily completed thirty-session psychotherapy for an adult man who sought therapy for relief from his depression.     

Unresolved attachment among immigrants: an analysis using the adult attachment projective

Dutch and Belgian immigrants in California have a high rate of unresolved attachment status compared to nonimmigrant Californians, unrelated to their length of time in the United States, to their marriage status, or to their reasons for immigration. In this study, the author analyzes attachment at the representational level by comparing coherence in responses of 69 immigrants (29 men and 40 women) and 30 nonimmigrants (12 men and 18 women) to drawings in the Adult Attachment Projective (AAP; C. George & M. L. West, 2001; C. George, M. L. West, & O. Pettem, 1999). Analysis of variance indicates that being unresolved with regard to attachment is linked to greater perception of danger in general, and to a lower ability to resolve danger once perceived. Resolution of danger in story responses to AAP images shows that the immigrant group is most troubled by images of departure and isolation, but nonimmigrants are most disturbed by images of illness.     

The elephant tied up with string: a clinical case study showing the importance of NHS provision of intensive,time-limited psychoanalytic psychotherapy treatments

Prof. Richard Layard's influential advocacy for greater provision of ‘evidence-based’ psychological therapies, based in part on an economic rationale, has lead to greatly increased provision of cognitive behavioural therapy (CBT) and short-term therapies for depression, through the Increasing Access to Psychological Therapies (IAPT) initiative, whilst longer-term psychodynamic treatments are under threat, criticised as lacking an evidence base. This paper argues for the continuing provision of intensive thrice-weekly psychoanalytic psychotherapy treatments, time-limited to two years. It does so by describing such a treatment within an NHS psychotherapy department with a patient with a long history of severe personality pathology, including significant levels of perversity. The paper describes the patient's difficulties and his movement through the treatment, focussing on his difficulties making genuine emotional contact, his destructiveness of such contact, his acting out in the treatment, his perversity and the vital working through of the ending. The shifts the patient made are described, and follow-up information on the patient is given. The paper discusses the unique benefits of time-limited treatment and intensive psychoanalytic treatments for this ‘hard-to-help’ group of patients, and the economic rationale that can be made for such treatments.     

APP conference summary

This is an account of the extended assessment of a 22-year-old man who was initially sent for a court report, having been accused of setting fires. He had a history both of delinquency and, importantly, of childhood asthma. Although he proved unable to engage in psychotherapy, some management was provided, such as Winnicott advocates in cases of delinquency. This paper explores the symbolic meanings and functions of the patient's delinquent acts, drawing upon theoretical concepts from Freud, Aichhorn, and Deutsch. Of particular importance is the link between this patient's delinquency, his asthma, and the unresolved mourning for his dead mother which he carried not simply for himself but for his whole family.     

Working with and ‘seeing through’ the sexual transference in the psychotherapy of an adolescent boy

This paper explores the challenges and developmental opportunities of working with the sexual transference in psychotherapy with adolescents. Psychoanalytic contributions investigating the nature of adolescent sexuality and the developmental move from a narcissistic organisation to a capacity to form intimate relationships are reviewed, and the question of what happens when there is a lack of containment in infancy is addressed. The way in which unintegrated sexual impulses and phantasies can invade the therapeutic relationship is further discussed through the account of the weekly psychotherapy of a 16-year-old boy who formed a powerful sexual transference to his female therapist. The paper highlights how working through the sexual transference enabled this young man to face his developmental paralysis and begin to use the therapy as an opportunity for psychic growth.     

Prenatal psychotherapy and maternal transference to fetus

The psychodynamics of normal pregnancy include ambivalence, identification with the fetus as an outside object, as a part of self, and, finally, as a separate person. Positive and negative attributes can be projected upon the fetus. In infant-centered maternal psychotherapy, the infant often serves as a transference object. Many disorders of attachment or disorders of early parenting have their origins or manifest themselves in the prenatal period. During prenatal psychotherapy, the fetus can serve as a transference object. Review of the literature reveals conflicting views with regard to the effectiveness of prenatal psychotherapy. The developmental crisis of pregnancy may lead the woman to resolution of underlying problems with early detection and intervention. Review of the literature reveals cases of disorders of attachment and disorders of early parenting starting prenatally related to the mother's difficulties with her own parents or siblings. Case studies of prenatal psychotherapy demonstrate the role that the fetus plays as a transference object in the mother's efforts to rework some conflict from her own infancy or childhood.     

The role of the body as the medium in child psychotherapy: snapshots of therapy with an 11-year-old,severely abused,multiply placed girl

In Victoria, Australia, children with a history of abuse and severe attachment difficulties, and who have experienced multiple carers and placements, have been traditionally viewed by mental health services as unsuitable for psychoanalytic psychotherapy. A number of factors, including the lack of integrated, long-term case planning; unstable residential placement; and the belief that psychotherapeutic treatment will be of an extended duration, have influenced the decision not to provide individual psychotherapy for these children. Currently, the movement within mental health services is towards responsive and briefer treatment models. The child psychotherapist is challenged to re-think theory, technique and practice. This paper identifies contextual constraints that have led to these children being precluded from accessing psychotherapy. An alternative model of intervention is discussed and illustrated with clinical material. The contributions of Alvarez, Trevarthen, Schore and other writers are drawn on to underpin the clinical work. This model involves a change in technique and role and the use of a time-limited intervention. Intrinsic to the model is the understanding of the child's psycho-biological experience of trauma and disrupted attachment. The child's experiences are conveyed in the pre-verbal, gestural domain to enable history to be given voice.     

A Mother,A Baby,and Two Treatment Approaches: Discussing A Switch Case from CBT and Mentalization Perspectives

ABSTRACT

As the literature on perinatal depression and anxiety grows, there is an increased need for dialogue among theoretical approaches for mother-infant mental health. This article describes a community mental health program incorporating a range of treatment models for pregnant and postpartum women experiencing issues during the transition to parenthood. Perinatal distress can affect parenting practices, from breastfeeding to health care access, creating the need for targeted, practical, and concrete interventions. Interventions that aim to foster secure attachment relationships and mentalization capacities can also help increase maternal sensitivity and attunement and joy in caregiving, and reduce withdrawn/hostile behaviors that may be associated with perinatal distress. The article describes psychotherapy with a mother and her newborn that began from a cognitive-behavioral approach and transitioned to a psychodynamic mentalization-focused treatment. Working principles and examples of two additional components of treatment, a group psychotherapy and research measures, are discussed. The case helps demonstrate how attachment theory can inform treatment and build a bridge between alternative approaches.     

On stealing clinical notes on three adolescent boys

In this paper I wish to explore the problem of stealing as a disturbance related to difficulties in coming to a recognition and acknowledgement of the need for an object with all this implies. To illustrate I should like to report sessions from three adolescent boys, beginning with John, a 19 year old boy whom I had been seeing once-weekly for psychotherapy. He was in his first year at College and came to treatment for, inter alia, examination difficulties. He was of high intelligence, and was not succeeding as he should.     

The body and sublimation in a violent male offender

A case study of a violent young man called Stan is presented to understand the nature and function of his violence as he negotiated his way through anxieties about heterosexuality and passivity stimulated by his adolescence. Stan’s early history and the clinical material are used to illustrate Armando Ferrari’s concept of the Concrete Original Object. As his psychotherapy progressed he utilised his talent for drawing to sublimate his violent activity into violent images, which, in turn, enabled him to reflect on his anxieties. Stan’s violence subsided and he was able to engage in a vocation and develop a long-term relationship with a woman.     

Changes of attachment status among women with personality disorders undergoing inpatient treatment

Background: Attachment has increasingly received attention in psychotherapy and has been used as a predictor of process and outcome. Studies investigating changes of attachment styles during psychotherapy are very rare. Method: Forty women with either borderline (BPD) or avoidant personality disorders (AVPD), treated as inpatients, were investigated using an attachment interview (interpersonal relations assessment (IRA)), and questionnaires to determine therapy outcome at the beginning and after seven weeks of therapy. The IRA uses similar questions as the adult attachment interview (AAI) and is used as the basis for the adult attachment prototype rating (AAPR), a procedure to assign individuals to prototypical categories of attachment. Results: The study showed that the therapy in general was effective. In contrast to other studies, we did not find many women classified as secure at the end of their therapy. Comparisons of pre‐post‐ratings revealed instead that clients within both subgroups received higher ratings for the avoidant prototypes at the end of therapy, indicating deactivation of attachment. Changes from ambivalent to avoidant attachment were linked with better outcome among women with borderline personality disorder (BPD). Conclusions: This study adds further evidence to the result that attachment styles do not change dramatically during a time‐limited psychological treatment of personality disorder. Instead, the study showed that features of preoccupied/ambivalent attachment were less significant after seven weeks of therapy. For women with BPD, these changes were linked with a more favourable outcome which might reflect a more structured and deactivated attachment status as a result of inpatient therapy.     

The subjectivity of the mother in the mother–son relationship. Attachment,separation, and autonomy

Abstract

Margaret Mahler and John Bowlby's positions are crucial in understanding the tensions that can arise in mother–son relationships. A more recent development of a systems view illuminates the co-construction of this relationship that occurs mainly out of awareness. A systems model of development that describes the co-construction and bi-directional influence between mothers and sons will be used in this paper. The often-neglected subjectivity of the mother is the focus, and the relationship between the mother and her adult son is viewed as a process whereby all participants strive to achieve a balance among attachment, separation, and autonomy. In addition, the contributions of the mother and the impact on her of the son's difficulties in attachment, separation, and autonomy are highlighted. In a case illustration, the subjectivity of the mother in relation to her son is explicated, showing how the son distances himself from his mother and why themother is at a loss to understand how and why this has occurred. The mother's perspective was dominated by anger and disappointment toward her son as well as by self-blame and self-justification. As a result of psychotherapy, the mother was enabled to come to terms with the estrangement of her son.