Complete psychotherapy: Healing the phenotype

The concept of the phenotype is presented here as an integrator for psychotherapeutic and psychopharmacological knowledge. Some criteria which the therapist may find useful in pursuing nature/nurture resolutions are suggested by exploring this concept and its implications in the context of the present state of knowledge. The goal of this paper is to help refine the therapist's judgement on the nature/nurture causal components of the client's difficulties, and to help the therapist to better distinguish between healing which is effected without pharmacology versus those forms of healing which are better realized with it. A concluding section digresses to the potential for psychomathematical models to help achieve resolution.     

Some Aspects of Group Dynamics

The authors examine the nature of the relationship between the group members and the group therapist and discuss the reasons underlying therapeutic frame failure. It is argued that competing viewpoints concerning the nature of the therapeutic relationship in group therapy have eventuated in problems in articulating a generally accepted frame definition. The authors propose a formulation of the frame for long-term groups that embraces therapist anonymity, total confidentiality, and neutrality. Finally, instances of frame violation are viewed as stemming from the therapist's need for objects, the attempt to forestall various types of transference, and the need to provide an avenue for the therapist's narcissism. Clinical material is used to illustrate group members' responses to therapist-induced frame failures.     

Tele-counselling for Problem Gambling: A Case Study

Innovative approaches to the treatment of pathological gambling are required since the number of individuals who seek treatment tend to be fewer than the prevalence studies would indicate. In this study, an innovative approach to the treatment of pathological gambling was used in order to address the common hindrances to treatment-seeking these patients face. One such approach is to offer the option of manual-guided tele-counselling. This case study reports on the progress of one individual who was treated using this modality. For reasons of privacy and anonymity, the individual in this case report preferred to address her problem gambling with the assistance of a therapist whom she never met. The client was provided with 10 weeks of tele-counselling treatment during which six treatment modules were delivered. Problems of access, privacy and anonymity were overcome with this method and the client was able to reduce their gambling behavior significantly with the therapeutic gains being maintained at the 6-month follow-up. The implications for the treatment of problem gambling using a non-traditional approach are discussed.     

The attenuating effect of mortality salience on dishonest behavior

People are easily tempted to engage in dishonest behavior when an incentive is given and when full anonymity is provided. In the present work, we investigated existential threat as a motivational factor that might reduce dishonest behavior. Research based on terror management theory has found that mortality salience increases the motivation to fulfill salient values of one’s cultural worldview. Assuming the concept of honesty is important to human societies, we hypothesized that mortality salience will reduce dishonest behavior when the concept of honesty is salient. In two experiments, we assessed dishonesty under full anonymity by applying a die-under-the-cup paradigm with the expected value serving as a stochastic baseline for honest behavior. Both experiments provided support for our hypothesis. Given an incentive to cheat, when the concept of honesty was cognitively activated by a word-search puzzle (Study 1) or by the name of the dice game (i.e., “honest game”; Study 2), mortality salient participants showed not only less dishonest behavior but actually honest behavior.

     

Feeling like a good psychotherapist — Or a bad one: Critical incidents in psychotherapists' experiences

What makes a therapist feel competent or incompetent in a session, a concept related to the good — or bad — hour, is an implication of what the therapist believes is good therapy and therefore is trying to do — or believes is bad and therefore tries to avoid doing. In an attempt to infer covert processes in therapists, twenty-seven psychoanalytically-oriented psychotherapists furnished written accounts of sessions when they had felt like good — or bad — therapists. Accounts were analysed and interpreted to uncover the varieties of good and bad experiences and their grounds. Resistance and countertransference were found to be critical phenomena. When the therapist was able to cope with such complications, good feelings were generated, and when he was unable, bad ones — provided he became aware of this inability. If not, the therapist acted out patient-specific or unspecific countertransference feelings in ways that made him feel like a good therapist.     

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 variability of client,therapist and clinic in psychotherapy outcomes: A three-level hierarchical model

This article investigates the percentage of variance in psychotherapy outcomes explained by the case-mix variables for individual cases, by the therapist (therapist effects), and what additional variance is explained by the clinic with which the therapist is affiliated. While there has been substantial recent research regarding therapist effects, very little has been published regarding clinic-level effects after controlling for therapist effects. The study utilised the largest sample reported to date, using data from 28 clinics with a minimum of 2,000 cases in a clinical range of severity of symptoms with pre-post change scores on an outcome questionnaire. Only cases treated by a therapist with at least 30 cases were included. These selection criteria resulted in a case count of 156,258 clients treated by 874 therapists located at 28 clinics. After controlling for differences in case mix using diagnosis and intake score (severity of symptoms), the resulting analyses indicated that 5.21% of the variance in treatment outcome was explained by the therapist, while another 1.13% of the variance was associated with the clinic. Findings are discussed with implications for practice and policy.     

The Mania of Existence: Klein,Winnicott, and Heidegger's Concept of Inauthenticity

This paper offers a new interpretation of Heidegger's concept of inauthenticity (Uneigentlichkeit) in Being and Time. It breaks from the “conformity interpretation” of inauthenticity, according to which the anonymity of the inauthentic person is due to her conformity to das Man. Rather, it argues that the anonymity of the inauthentic person is due to “existential mania” – a state in which a person denies her death and anxiety, understands her abilities to be limitless, and is perpetually active. It shows how this existential mania – and the anonymity to which it gives rise – is analogous to the mania described by the object relations psychoanalyst Melanie Klein. Finally, drawing on D. W. Winnicott's discussion of mania, it shows how both the inauthentic person's conformity to das Man, and her existential mania, give rise to anonymity.     

Wearing uniforms and aggression–A field experiment

Zimbardo's de-individuation concept was tested in a field experiment using games of fieldball. The results support the assumption that higher degrees of anonymity lead to more aggressive acts.     

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.     

Brief encounters and available places to land

In this paper the author addresses the process of ending in brief therapy. While recognizing the importance of attending to the symbolic meaning of the ending itself and the need to interpret this as it manifests in the transference, he points out the limitations of such an approach. He highlights the significance of the environment of interpersonal relationships and family systems and the wider communities in which the client lives. He suggests that the therapist needs to assess the extent to which these can provide an environment that facilitates the client's development and working through as the therapy ends. The therapist needs to establish whether the patient will have an available place to land, and one that provides sufficient security and safety for the client's onward journeying and exploration without the therapist. The author's conceptualization of 'landing at the end of brief therapy' links together Malan's triangles of insight with Sullivan's concept of the ordinary solution and selective inattention and Gustafson's concept of dilemmas to add depth to the therapeutic effectiveness with which the practitioner can approach brief therapy in general, and the ending in particular. The article concludes with a case example that illustrates these themes.     

Divorce therapy: an in-depth survey of therapists' views

In-depth interviews were conducted with 21 highly experienced therapists on the criteria of a constructive divorce, the obstacles to achieving such a divorce, and the strategies and tactics of divorce therapy. The primary criterion of a constructive divorce was the successful completion of the process of psychic separation and the protection of the welfare of minor children. Therapy may focus on the decision to get divorced and/or the negotiation of the terms of a divorce settlement. Three types of therapeutic strategies were identified: reflexive intervention by which the therapist orients himself to the marital problems and attempts to gain the trust and confidence of the partners; contextual interventions by which he tries to promote a climate conducive to decision-making; and substantive interventions intended to produce resolution on terms the therapist has come to believe are inevitable or necessary. The nascent state of divorce therapy as an area of therapeutic specialization is noted. The problem of diagnostic criteria for divorce, the relationship between therapists and lawyers, the nature and consequence of therapist impartiality, and the degree to which therapists should mediate the terms of divorce are considered central issues meriting further study.     

Navigating the Unknown: Towards a Positive Conception of Anonymity

Talk of anonymity floats freely and, in many contexts, rampantly in everyday, nonphilosophical discourse. But despite a surge of interest in anonymity—in anonymity protections, on the one hand, and anonymity harms and abuses, on the other—it is not at all clear what anonymity is. Is it simply a matter of being unknown? Or is anonymity something more, or less, than this? Unfortunately, existing analyses frame anonymity very generally as a phenomenon of unknowability and/or concealment. Consequently, they fail to capture what distinguishes anonymity and anonymity relations from, for example, privacy and privacy relations. In this paper, I explore a more precise way of articulating anonymity, developing what I call the “central anonymity paradigm,” which frames anonymity as the result of a specific exercise of control in which true pieces of information about a person are concealed from others with an effect of dissociability. I use this paradigm to show how anonymity is characteristically interpersonal and network‐relative, and deeply connected to issues of personal identity.     

The Bilingual Therapist and Transference to Language: Language use in Therapy and its Relationship to Object Relational Context

Through the concept of transference to language, this paper examines the clinical impact of language-related selves of a bilingual therapist, the origin of which is based on the idea that language develops in an object relation context.     

Patients’ Pregnancies During Treatment: The Influence of the Analyst’s Psychology

Psychoanalytic therapists are today far more aware of countertransference effects, intersubjectivity, and mutual influence. The area that has been explored least in this two-person appreciation of psychoanalytic process is the effect of the psychodynamics of the therapist in a wide sense—that is, how the therapist brings a whole psychology, with a wide array of potential transferences, to each treatment. Triggered by the unexpected announcement of a patient’s expecting a baby, the author reviewed his practice and found that a large portion of his women patients ages 30–45 had become pregnant during therapy or psychoanalysis. The particulars were varied: how much the patient wanted a baby, whether the treatment was psychotherapy or psychoanalysis, the patients’ personality structure. Was the analyst’s psychology a common factor? The paper presents three quite different case examples and examines whether and how the author’s developmental and inner experience of women, sexuality, pregnancy could have contributed to a dyadic process that, in turn, could lead to pregnancy. If such effects happen, then it is important to look beyond and behind “anonymity” and “neutrality,” as well as momentary countertransferences, to the real-life effects that we have in our treatments.     

Altruism and Boundary Violation

ABSTRACT

The desire to help others is a common motivation for becoming a therapist, and boundary crossings are an expectable part of psychotherapeutic work. However, progression to boundary violation is rare. The concept of an altruistic boundary violation is presented and illustrated with detailed clinical material drawn from the analysis of Mrs. A,¹ a generally ethical therapist, whose violation of the therapist/patient boundary with her patient, M, began as an altruistically motivated enactment and boundary crossing. In Mrs. A’s case, and arguably in all similar altruistic boundary violations, a specific fit existed between patient and therapist. The intense need to rescue this particular patient was fueled by Mrs. A’s history of early physical and abandonment trauma, which increased her vulnerability to overidentification with her traumatized patient. The stress of relocation to another city and closing her practice further magnified her susceptibility. The complex clinical, professional, ethical, and legal issues inherent in consulting on such a case are discussed. I describe my countertransference and my parallel enactment, an initial crossing of the boundary between the roles of supervisor and therapist.     

Patientensicht zur Qualität in der Psychotherapie

Concerning the discussion about the quality of psychotherapy, the different perspectives in the definition of quality are rarely considered. Especially the patients’ perspective is barely respected although quality assurance of psychotherapy should be for their benefit. Patients were interviewed (n=8) to answer the question which criteria of quality are relevant in their view. Using the grounded theory a variety of quality criteria was found. The interviewees emphasized the relationship between therapist and patient, the empathy of the therapist, the scheduling of appointments and the progress in therapy. The results suggest that when judging the quality of psychotherapy clients do not only focus on the outcome of psychotherapy, as presumed by some experts, but also on the dimensions structure and process. Professionals have to consider this fact when designing and applying methods of quality assurance.     

Cotherapist modeling in group psychotherapy: Fact or fantasy?

This study examines ratings of cotherapist self-disclosure furnished by members in 20 outpatient groups. Clients completed a specially designed measure to assess three dimensions of therapist transparency: positive or negative valence, low or high risk, and the target of the disclosure, namely, the individual members, the group as a whole, the therapist her/himself, or the co-leader. Exploration of the frequency of therapist-to-therapist disclosure provided an evaluation of the modeling hypothesis that is so prevalent in the literature. The findings demonstrate that although the overall level of therapist self-disclosure was quite low, results were consistent with expectations showing that most of the personal comments were positive, low risk, and rarely directed to the cotherapist. The viability of the modeling concept in co-led groups is challenged.     

Therapist Factors Matter: A Systematic Review of Parent Interventions Directed at Children’s Behavior Problems

The present review systematically explored research examining the relationship between therapist‐related factors and the outcomes of parent interventions directed at children’s behavior problems. A systematic search of the literature was conducted with online scientific databases, parenting programs, web sites, and bibliographic references of the selected articles, according to PRISMA guidelines. A total of 24 quantitative studies met the inclusion criteria. Although some methodological limitations were identified with respect to the measurement of therapist factors, the reviewed research strongly suggests that the therapist plays a critical role in parent interventions directed at behavior problems. In particular, many parent outcomes are found to be related to the parent–therapist alliance, the therapist’s fidelity to the intervention, specific therapist’s in‐session actions, and the therapist’s personal variables. The parent–therapist alliance and therapist fidelity to the intervention consistently relate to changes in parenting practices, and alliance additionally relates to fewer perceived barriers to participation in treatment, more treatment acceptability, and greater parenting satisfaction and self‐efficacy. In addition, specific in‐session therapist interpersonal actions relate to parents’ engagement and satisfaction, while both the therapist’s interpersonal actions and more active skills relate to parent change. Therapist’s personal variables have been scarcely or poorly studied to date, but the results found justify the need to develop further research in this area. In conclusion, more attention should be given to the role of the therapist when implementing parenting programs directed at behavior problems, and more and better research is needed that can overcome the methodological limitations identified.     

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.