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.     

Narcissistic leadership in psychotherapy groups

Narcissistic leaders in groups are capable of impeding progress of their patients and, at worst, can produce iatrogenic effects. Significant interferences may occur when the therapist is unable to tolerate the expression of negative transferences and when they need to be idealized by their patients. The rare therapist who is a malignant narcissist is capable of inflicting severe damage by sadistically exploiting the group to satisfy his or her own pathological needs. Less severe interferences consist of inhibition in making transference interpretations, reluctance to seek out training or supervision, and a difficulty in protecting patients against being scapegoated as a result of the displacement of negative feelings toward the therapist onto a member. The universality of these issues among therapists is discussed and possible remediation is proposed.     

Qualifications for Membership in the A.G.P.A.

A model of the development of group therapists is presented. It is proposed that student group therapists proceed through a sequence of stages, each of which is marked by characteristic therapist behavior. During the initial Group shock phase, the student reacts to the novelty of group therapy stimuli with individual therapy or content-oriented approaches. Reappraisal is a period of some therapist inhibition, frustration, or self-doubt. One step behind is a phase characterized by a gradual recognition of the process level of analysis, despite difficulty supplying the interventions autonomously. Using the here-and-now is a period of active intervention about interpersonal phenomena among group members. The techniques for highlighting this material are refined in the Polishing skills phase. The usefulness of models in training is discussed.     

Group processes and the therapist's subjectivity: interactive transference in analytical group psychotherapy

Interactions among the group therapist, the group members, and the group as a whole, especially enactments, are conditioned by the therapist's identity, defenses, and present relationships within his or her social networks. It follows from these considerations that difficulties in a group process stem from the group therapist's inability to understand well-enough what the group members are acting out and that they can be overcome only if the therapist extends the limits of his or her identity. Therefore, it has to be taken into account that the leader of a group is always a member of other groups whose dynamics in turn determine one's capability to understand the interactions in the group in which he or she is a therapist.     

Developing countertransference awareness as a therapist in training: The role of containing contexts

The psychodynamic literature suggests that countertransference is an inevitable part of therapy and a significant feature of the client-therapist relationship. However, countertransference is also considered to be a ‘double-edged sword’: when it is reflected on by the therapist, it can offer valuable insights into the therapeutic relationship, but when it remains outside of awareness and therefore unmanaged it can result in the therapist unwittingly acting out in the therapeutic relationship and responding in counter-therapeutic ways. The purpose of this research was to explore the factors involved in the development of countertransference awareness in therapists and to construct a grounded theory of the process. Fifteen qualified therapists were recruited and interviewed, either face to face or via Skype, using a semi-structured interview schedule. The grounded theory constructed from the data suggests that during training participants initially experienced countertransference as threatening and overwhelming. When this experience was contained in supervision and therapy, the organisational context and by participants’ theoretical framework, they could reflect on their countertransferential responses and make sense of their experience, which then developed their self-awareness and other insights to the benefit of the therapeutic relationship. Conversely, a lack of containment in these domains resulted in participants acting out their countertransference and becoming either over or under available in the therapeutic relationship. The findings offer a useful process model on the role containing contexts play in the development of countertransference awareness for therapists in training.     

The Relationship Between Momentary States of Therapist Self-Awareness and Perceptions of the Counseling Process

To investigate the role of momentary self-awareness, beginning therapists and their volunteer clients participated in a postsession process recall in which therapist helpfulness and momentary self-awareness were assessed along with client reactions. Therapist anxiety levels and strategies used to manage hindering self-awareness were also examined. Results suggest that momentary states of heightened therapist self-awareness may be hindering. Specifically, when therapists rated themselves as more self-aware from moment to moment during counseling sessions, they also rated themselves as more anxious before the session and their clients rated them as less helpful during the session. In addition, therapists reported using a variety of strategies to manage distracting self-awareness, including focusing on intervention planning and focusing on the client. Implications for therapist training are discussed.     

The new member: "infanticide" in group psychotherapy.

While the variety of responses of psychotherapy groups to new members is wide, this article addresses those that are treatment destructive, that is, murderous in that they are aimed at the elimination of a new sibling. A number of frequently encountered destructive response patterns to new members are illustrated and categorized. It is suggested that survival of the new member is best insured by adequate preparation of the group so that the nucleus of powerful feelings activated in this situation can be felt and expressed prior to the addition of the new member. A clinical example of appropriate preparation is offered, and the contributions of group therapists to new member casualties are noted.     

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.     

‘The experiencing of experience’: a Pragmatic reassessment of Rogerian Phenomenology

This paper draws on a study that asked twenty family users about their first session of family therapy. Analyses of the interviews indicated that families entered therapy with a pre-existent knowledge about therapy, which did not always chime with those of professionals and which positioned speakers in ways which governed their expectations and perceptions of therapy. This paper, therefore, is concerned with the acquisition and deployment of knowledge: specifically, the knowledge involved in being a user of family therapy. Three key discourses were identified through this analysis: medical, counselling and consumerist. We aim to illustrate how these discourses served as a resource for members of the family in constructing therapists, therapy and themselves in relation to their experience. The examination of the rhetorical, ideological and practical effects of the positions chosen and the objects constructed, in terms of how speakers wanted to present themselves, with what enhanced or diminished status as patients, shows users actively engaging with the power of therapeutic institutions. Users’ accounts suggest that while most speakers felt anxious about the prospect of therapy, there were clear differences in overall satisfaction/dissatisfaction with the experience according to the synchrony between speakers’ construction of the therapist, and themselves as client/patients. Those who seemed to take a traditional view of therapy within a medical discourse valued therapists who offered diagnosis and a cure; those who sought and experienced a counselling relationship with the therapist found their experience to be constructive in terms of enhanced self-knowledge. We believe that the research findings discussed in this paper have implications for family therapists in accommodating to parental and child positions to maximise the effectiveness of therapy and so minimise drop-out.     

Family and couples therapy with gay and lesbian clients: acknowledging the forgotten minority

Family and couples therapy in the main concentrates on heterosexual clients, and has thus been described as limited in its outlook, or discriminatory. It is argued that family and couples therapy is at present not offered to gay and lesbian clients because of an absence of appropriate referrals, the inability of therapists to recognize the sexual orientation of their clients, a belief that skills held by therapists are not appropriate for this client group, or because of the homophobia of the therapist. It is suggested that family and couples therapy should be more readily available for gay and lesbian clients, and a number of different issues which these families might face are discussed. This includes problems associated with the gay adolescent and the gay or lesbian parent, as well as the gay or lesbian couple. It is concluded that established forms of intervention are effective with gay clients, provided that the specific needs and problems of the gay and lesbian community are addressed by the therapist.     

ABSTRACTS OF LITERATURE

This is a clinical essay with case examples stressing the point that pathological families have not been proven to be a cause of schizophrenia and therefore indiscriminant blame and mistrust of the family, overtly or covertly, by the treating therapist is not helpful to the identified patient or his family. Suggestions to help therapists treat families are made.     

The therapist's anxiety and resistance to group therapy

When therapists contemplate starting groups, consider placing an individual patient within an existing group, or respond to the group reconfigurations when members are added or replaced, it raises their anxieties and resistances. Under these circumstances, the therapist must contend with many intersubjective factors: dread, fear, and idealization of groups; contagion and amplification of psychological phenomena; absorption in the group mentality; magnification of the therapist's centrality and importance; exposure and disturbance of existing relationships, and utilization of one's own emerging and evolving thoughts, feelings, and fantasies, along with the group's. Therapists learn about themselves and their groups by reviewing their countertransference, being alert to possible enactments, and listening to their patients, whose anxieties and resistances to group often reflect their own.     

Ontological and epistemological reflexivity: A core skill for therapists

This paper argues that a core skill needed to be an effective therapist is to have developed an awareness of one's own ontological and epistemological positions in relation to one's work as a therapist. In the same way that researchers need to develop reflexive awareness of their assumptions about what there is to know (ontology) and how they can come to know about it (epistemology), therapists need to be aware of their fundamental assumptions about human beings and the world they live in (ontology), as well as their beliefs about how best to develop an understanding of their clients and the meaning(s) of their experiences (epistemology). Regardless of which therapeutic model is adopted, the language used to talk about (and in) therapy, the kinds of questions asked of clients and the comments/interpretations offered, all presuppose and reinforce particular versions of human being and experiencing, which are themselves not usually questioned or challenged during the course of therapy. It is essential that therapists are aware of their own fundamental assumptions about what it means to be human and that they recognise their ontological and epistemological positions as positions that they are taking (rather than perceiving them to be self‐evident truths). This is important for two reasons: (a) if clients do not share the therapist's assumptions, the therapeutic work cannot proceed and be effective; and (b) without such an awareness, therapists are at risk of unwittingly imposing their own model of the person upon the client which raises ethical issues.     

Cause and responsibility: towards an interactional understanding of blaming and 'neutrality' in family therapy

This paper aims to shed light on the ways in which 'neutrality' is both produced and resisted by socially competent actors in family therapy sessions. It draws upon recent and previous papers in this journal ( Stancombe and White, 1997; Stratton, 2003a, 2003b ), which highlight the importance of blame in therapeutic encounters. When families come to therapy, individual members frequently deliver competing accounts about the family troubles and who is to blame for them. This produces particular challenges for the therapist. We examine the practices of therapists in managing accountability in the session and in their own discussions. Family therapists operate with a professional ethic of neutrality, or multi-partiality. This paper is concerned with the linguistic strategies used by therapists to deal with overtly blaming accounts, how these strategies are responded to by family members in talk-in-interaction and how therapists go about crafting accountability-neutral versions. We show that the social and moral context of family work makes the therapist's job of communicating multi-partiality precarious. In producing accountability-neutral versions of families' troubles, therapists are forced to make practical-moral evaluations of competing versions of events. We conclude by arguing for a more explicit engagement with the moral nature of therapeutic practice.     

Perceptions of the therapist in family therapy

Thirty-five families completed ratings describing their perceptions of their therapists. These ratings were then correlated with measures of outcome to assess whether there was a relationship between experiences of the therapist and treatment outcome. Further, the study addresses whether some family members' perceptions are more influential in affecting the course of treatment. The results showed that family members' perception of the therapist does have an impact on treatment outcome, but not all members affect the outcome equally. Further results and their implications are discussed.     

A Pilot Study Implementing Coping Power in Italian Community Hospitals: Effect of Therapist Attachment Style on Outcomes in Children

The study presented the initial report of a project regarding the implementation of the Coping Power Program in Italian community hospitals, and the program’s ability to reduce externalizing behavioral problems in children with a Disruptive Behavior Disorder diagnosis. Usually, interventions for children are implemented by a number of therapists with different personal characteristics, which therefore influence the implementation quality of an intervention. That said, the present study aimed to establish whether the insecure attachment styles of therapists predict unfavorable outcomes for children treated with the Coping Power Program. The sample included 80 children with a Disruptive Behavior Disorder diagnosis and 16 therapists. The results showed that the change in children’s aggressive behavioral problems was significantly related to the levels of the therapist’s preoccupation with relationships. Higher levels of change in aggression (where a higher value means that the aggression at the end of the treatment is higher than aggression at the baseline evaluation) are associated with higher levels of therapist’s preoccupied attachment style (anxious attachment style). This study provided some preliminary evidence that therapists need to be sensitive to their own attachment experiences when delivering therapy for children.     

The impact of transference and countertransference in activity group therapy

The effective use of countertransference reactions in children's group psychotherapy is discussed. Countertransferences activated by the group dynamics or by the dynamics of individual group members must be analyzed and understood by the therapist if they are to be utilized. The analysis of resistances in children's therapy groups is enhanced by the therapists' awareness of their own countertransference reactions. Clinical examples are presented.     

A Group Journey—to Hell and Back

The process of a therapy group in an inpatient daycare unit¹ became saturated with anger and detachment, ultimately leading to a despairing silence. Based on Ferenczi’s concept of Orpha, I will explain the group silence as indicative of deep trauma and dissociative self-states. I propose that the therapist’s willingness to “hang in” with his group and be part of a seemingly unbearable enactment enhances the possibility for emergence of hope and restoration of positive communication. It is rare in the literature for authors to expose the pitfalls that they and their group members can fall into, leading to despair, shame, and hopelessness. When working in the complex environment of a mental hospital where every level of staff is stressed, therapists often find themselves without support and consultation. My hope is that my colleagues can learn from my challenges, errors, and lessons, as I have.