The development of therapeutic attitudes during and after psychotherapy training

The aim of this study was to explore changes in psychotherapeutic attitudes of students during training in psychodynamic psychotherapy and the first few years after it. Forty-six students were asked to answer a therapeutic identity questionnaire at three times during training and at one time after it. Twenty-one students completed the questionnaire on all four occasions. The questionnaire assessed attitudes on nine scales relating to beliefs about curative elements in psychotherapy, therapeutic style, and basic assumptions about psychotherapy and human nature. At the beginning of training, students had a clear psychoanalytical orientation, similar to that of their supervisors. From the last year of training, after supervision had ended, and continuing during the post-training period, students distanced themselves from the psychoanalytical orientation and their supervisors toward a more eclectic position. This development may reflect the formation of an autonomous therapeutic identity.     

My subdued ego: A psychodynamic case study of borderline personality disorder following relational trauma

Recent advances in the conceptualisation of borderline personality disorder (BPD) have highlighted the role of relational trauma as central to the onset of the disorder, whilst observing deficits in the structure of the self-concept as a result of developmental adversity. Understanding borderline states within a psychiatric framework alone has attracted significant criticism due to the lack of the medical model’s explanatory properties, which fail to account for the complexity and variation of borderline symptomatology. A reliance on psychodynamic formulation instead, can provide an aetiological framework where BPD can be understood as a disorder of the sense of self, originating in the client’s relational matrix. The purpose of the current paper is to discuss a borderline case study with a focus on formulation rather than diagnosis, in an attempt to shed light on the relational and unconscious processes underpinning the disorder and thus inform treatment interventions.     

Three fragments on trauma and time

How does trauma influence a client and a therapist’s experience of time in time-limited therapy? The therapist must first work to understand and remain responsive to the different registers of time now operative following the traumatic event. This paper contends that in the immediacy of trauma, hallucinatory wish-fulfilment oblivious to the structuring conditions of time and space appears to dominate. In chronic traumatic states, time appears to circle in a narrow compass, buffering between a cluster of moments surrounding and including the moment of traumatic rupture – as if struggling to re-establish a secure connection with linear time. The three clinical fragments presented attempt to describe different experiences of traumatic bereavement and the felt movement of time within them. The death of another confronts us not only with their loss but with our own mortality – the time we have lived and the time we have left. It is not surprising, therefore, that an individual's otherwise fluid transitions between different temporalities are disturbed in the aftermath of traumatic bereavement. The therapist’s capacity to regulate tempo when the client’s subjective experience of time is dysregulated offers an important means of containment. The aim of the therapist working with the traumatically bereaved client is to develop collaborative understanding to get thinking moving again and to gradually help the client unpin time, moving it beyond the confines that it occupies in trauma.     

The time of our lives: Psychological disorders,time perception and the practice of mindfulness

Psychological disorders are associated with a wide variety of distortions of time perception. In this paper, I briefly review what is known about time perception and its disorders and suggest that the practice of mindfulness may be effective by virtue of its effect on our relationship with time.     

The child's experience of Munchhausen syndrome by proxy

This paper examines the emotional impact of Munchhausen syndrome by proxy on a child aged 6 who had been poisoned by her mother. It describes her treatment in child psychotherapy over twenty months at the Cassel Hospital where the family worked towards her successful rehabilitation home. The work with her showed her experience of dangerous relationships in her family that left her distrustful of any new relationship, and doubtful of her capacity to be close without being destructive. Like her parents, she was terrified of facing the murderous feelings in the family, retreating into denial when life was too painful. The paper describes three phases of treatment: fear of separation and preoccupation with the trauma of poisoning, ambivalence about facing the destructiveness in the family and the move into more appropriate latency behaviour as she prepared to go home with her parents. It concludes with an overview of the impact of Munchhausen syndrome by proxy on the developing child, as shown in this treatment: the delay in emotional and cognitive development, the interference with the capacity to relate, the retreat into illness under stress, and the fear of permanent damage caused by the emotional and physical abuse.     

Suicide risk in the detachment from reality: failures in the quest for love that saves

Suicide is among the leading causes of death worldwide, accounting for almost one million annual deaths globally. The author presents an exploration into the suicidal mind using Freud's cathexis and decathexis theory. This model describes the patient’s withdrawal from reality and the need to gratify libidinal and aggressive drives in the internal world. Theories and beliefs of other authors are used to introduce the importance of early disturbed relationships with parental figures. Working with the particular subtype of suicidal patient described in this essay may be a challenge for clinicians. A psychodynamic approach may help in the understanding of the patient’s complex and private world of psychological pain. If unresolved, the patient’s conflicts may precipitate suicide.     

A systematic review of the effectiveness of psychoanalysis,psychoanalytic and psychodynamic psychotherapy with adults with intellectual and developmental disabilities: progress and challenges

Objectives: This systematic review aimed to critically appraise the literature on the efficacy and effectiveness of psychoanalysis, psychoanalytic and psychodynamic psychotherapy in adults with intellectual and developmental disabilities (IDD). Method: A systematic search of electronic databases was carried out. The methodological quality of the studies was assessed using a quality assessment tool and comparisons were made with a review of the quality of research on the effectiveness of cognitive behavioural therapy (CBT) for people with IDD. Results: The search yielded 13 papers which provided evidence for the effectiveness but not efficacy of psychoanalytic and psychodynamic psychotherapy; but none were found for psychoanalysis. The quality of the research was generally poor compared to the current research on the effectiveness of CBT. Conclusions: Positive outcomes have been indicated for psychoanalytic and psychodynamic psychotherapy with people with IDD. Larger scale, more controlled research is necessary to advance the evidence base.     

The advantages of formulation over categorical diagnosis in explorative psychotherapy and psychodynamic management

In neurosis and personality disorder, formulation is a clearer guide to aetiology, prognosis and treatment than is categorical diagnosis. Diagnosis and formulation have different and complementary functions. The formulation is an essential component in explorative psychotherapy but also has wide application in psychodynamic management. The content and the making of a formulation are described. the value of a psychodynamic approach in decision making, and in choosing between explorative psychotherapy and psychodynamic management, is illustrated by case examples.     

The development of an evidence-based treatment: Regulation-Focused Psychotherapy for Children with externalising behaviours (RFP-C)

There is a critical need for the development, evaluation and implementation of evidence-based psychodynamic treatments for children and adolescents. Currently, there are no empirically supported, manualised psychodynamic treatments for children and adolescents with disruptive behaviour problems. The field of manualised psychodynamic treatments with measurable equivalence or superiority to other established forms of psychotherapy is in its nascent stage. This paper details a novel, manualised, time-limited psychodynamic treatment approach for children who manifest disruptive behaviours and emotional dysregulation. Regulation-Focused Psychotherapy for Children (RFP-C) conceptualises children’s disruptive and acting out behaviours as expressions of maladaptive emotion regulation. Externalising symptoms are conceptualised as attempts to defend against painful emotions and thus protect the child from disturbing feelings such as sadness, shame and guilt. This paper provides the theoretical basis for the treatment approach and through the use of a clinical example demonstrates the systematic application of RFP-C in a single case.     

The therapeutic community in the local community: Social networks between therapeutic community and supported housing

In this paper, the authors present a model for therapeutic community programmes for those with severe and enduring mental ill health, based on social networks. These programmes have given birth to a range of therapeutic community which are, in fact, an innovative form of group psychotherapy. These new model do not depend on communal living. Some are groupings of apartments, others day units. Work schemes also feature here. And yet, as the authors outline, various components need to be present if these are to be considered genuine therapeutic communities and not just supported housing schemes. Additionally, a certain kind of training and clinical supervision is needed for the staff.     

The emerging therapeutic landscape of psychotherapy in the twenty-first century and the contribution of anthroposophic psychotherapy

In recent years the counselling and psychotherapy profession has experienced significant changes. On the one hand there has been the advent of managed care and evidence based practice which in the UK takes the form of the Improved Access to Psychological Therapy scheme. On the other hand there has, during the same period since the 1980s, been a rich and varied process of innovation in the profession. This has included the so-called relational inter subjective turn in the United States. Second, an increased sensitivity to the interface between therapy and social and political phenomena. Third, the revolution in neuroscientific thinking. Finally, the development of therapy as an interdisciplinary intervention in complementary and alternative medicine teams as in the case of the spiritually-orientated anthroposophic psychotherapy in Europe. In this article I will argue that these innovatory developments, which I refer to as the ‘new integration’, are much needed in order to counterbalance the increasing dominance of managed care and evidence based practice.     

Facilitating the client's experience of relational depth in counselling and psychotherapy: A thematic review

Aim

There is increasing interest in relational depth and its relevance and benefits for clients receiving therapy in a number of different therapeutic orientations. This research set out to draw together the available evidence from a wide range of therapies about clients' experiences of relational depth. The aim was to identify approaches that create the conditions where relational depth is more likely to be facilitated. The research focused on clients' views, given the increasing emphasis on their experiences in therapy.

Methodology

A systematic search of papers published in English between January 1996 and September 2022 was conducted using EBSCO Host, Google Scholar and citation chaining. Twenty-seven papers met the inclusion criteria, and a thematic analysis was conducted on these papers.

Findings

Six themes were identified: (1) establishing dialogue with the client's inner world, (2) working with attachment in therapy, (3) responding sensitively to the client's beliefs and values, (4) deepening the client's understanding of the therapist, (5) addressing ruptures in therapy and (6) the client's role in meeting at relational depth.

Conclusion

Facilitating the client's experience of relational depth can support and enhance many aspects of therapeutic practice and in itself may contribute to healing. Therapists who offer warmth and genuine engagement are more able to build confidence and trust, as long as these conditions are received by their clients. It is the clients who ultimately decide whether or not to share their deepest feelings.     

Relational ecologies of psychotherapy: The influence of administrative attachment on therapeutic alliance

There is now vast and multi-faceted empirical literature on the impact of relational dynamics in psychotherapy, and relationality is a central theme within contemporary psychoanalytic theories. Yet, there is virtually no literature addressing the relational dynamics around outpatient psychotherapy that influence the wider therapeutic alliance, that is the relational dynamics that unfold between clients and administrative office staff in making initial contacts and appointments, completing paperwork, negotiating payment, discussing insurance coverage, working through crisis calls, and the myriad of other forms of interaction which serve to form the relational ecology of psychotherapy. Milieu therapy or the use of supportive and structured therapeutic environments has been given significant attention in inpatient settings; however, administrative relational factors or administrative staff characteristics have seemingly been ignored in outpatient psychotherapy and psychoanalysis literatures. Many outpatient clinical practice settings involve multiple levels and dimensions of relationality between clients, administrative personnel, and therapists which shape the potential for secure continuous containment and various forms of attachment to psychotherapeutic space. In this paper, we describe several clinical illustrations of relational dynamics between clients and office staff which influence therapeutic alliance and outline the contours of our emerging idea of administrative hospitality based on relational psychoanalysis, attachment theory, symbolic anthropology, and stigma research. In doing so, we draw on our collective experience working in several outpatient clinics and insights from our current context in an urban outpatient training clinic which emphasises psychodynamic practice. Our goal is not a comprehensive analysis of the relational ecology of psychotherapy but to offer an initial exploratory account of some of the administrative relational dynamics in and around outpatient psychotherapy which go beyond the therapist-client dyad. The anthropological concept of liminality is connected to relational psychoanalytic theories to describe the important dynamics of transitional space in an overall process of relational transformation.     

Psychodynamic psychotherapy for children and adolescents: a critical review of the evidence base

For many years psychoanalytic and psychodynamic therapies have been considered to lack a credible evidence-base and have consistently failed to appear in lists of ‘empirically supported treatments’. This study systematically reviews the research evaluating the efficacy and effectiveness of psychodynamic psychotherapy for children and young people. The researchers identified 34 separate studies that met criteria for inclusion, including nine randomised controlled trials. While many of the studies reported are limited by sample size and lack of control groups, the review indicates that there is increasing evidence to suggest the effectiveness of psychoanalytic psychotherapy for children and adolescents. The article aims to provide as complete a picture as possible of the existing evidence base, thereby enabling more refined questions to be asked regarding the nature of the current evidence and gaps requiring further exploration.     

Changes in meaning in life across the course of psychodynamic psychotherapy

Using the Meaning in Life Questionnaire (MLQ), we studied Presence and Search for meaning for 34 adult clients in psychodynamic psychotherapy. Clients completed the MLQ and Outcome Questionnaire (OQ) before intake and after every eight sessions. Variance in Presence scores was mostly attributable to clients; variance in Search scores was mostly attributable to clients and therapists. Clients initially high in Presence decreased and then increased back to initial levels; clients initially low in Presence increased and then decreased back to initial levels. Clients initially low in Search increased and then leveled off; clients initially high in Search decreased and then leveled off. In lagged cross panel analyses, when clients decreased in psychological distress during one eight-week time period, they increased in Presence during the next eight-week time period; when they increased in psychological distress during one eight-week time period, they increased in search in the next time period. Excerpts from post-therapy interviews illustrate the process of working with meaning in life in psychotherapy. Implications for practice and training are discussed.     

Psychodynamic psychotherapy for children and adolescents: an updated narrative review of the evidence base

While the evidence base for psychodynamic therapy with adults is now quite substantial, there is still a lack of research evaluating the effectiveness of psychodynamic therapies with children and young people. Those studies that have been carried out are also not widely known in the field. To help address the second point, in 2011, we carried out a review of the evidence base for psychodynamic psychotherapy for children and adolescents, which identified 35 studies which together provided some preliminary evidence for this treatment for a range of childhood disorders. The present study is an updated review, focusing on research published between March 2011 and November 2016. During this period, 23 additional studies were published, of which 5 were reports on randomised controlled trials, 3 were quasi-experimental controlled studies and 15 were observational studies. Although most studies covered children with mixed diagnoses, there were a number of studies examining specific diagnostic groups, including children with depression, anxiety and disruptive disorders. whilst the quality of studies was mixed, some were well-designed and reported, and overall indicated promising findings. Nevertheless, further high-quality research is needed in order to better understand the effectiveness of psychodynamic psychotherapy across a range of different disorders, and to ensure that services can provide a range of evidence-based treatments for children and young people.     

The Understanding and Treatment of Immigrant Trauma Survivors: Finding the Right Mix

This paper reviews attempts by three authors to describe psychoanalytic conceptualizations and treatment of torture victims. It argues that because the transference-countertransference configuration with immigrants who have not suffered torture is very similar to that of torture survivors, that no special diagnostic categories, theories, or treatment methods are needed to work with torture survivors. Second, the paper contends that newer psychoanalytic paradigms such as Hoffman's Social Constructivism may assist clinicians to capture the richness and complexity of clinical work with torture survivors better than do traditional analytic conceptions such as neutrality. Via an analysis of the three papers in this volume, I conclude with a consideration of the strengths and the weaknesses of the field of cross-cultural psychotherapy in general.