Problem-oriented sessions: Presentation of a method for therapeutic work within a narrow time frame

Abstract

A method of problem-orientation has been developed as a delimited psychotherapeutic procedure comprising four sessions with a psychotherapist. The distinguishing feature of this method is the distinct time frame, within which the therapist grasps the patient's current situation and difficulties. The sessions are disengaged from considerations about the need for further treatment. The therapist appeals to die reflective part of the patient and attempts to awaken their curiosity about themselves in order to explore inner associations concerning core problems. The four problem-oriented sessions are offered during the initial telephone contact to the person who wishes to gain a greater understanding of their own part in their difficulties and who is able, already in the introductory telephone conversation, to embark upon an exploratory dialogue about these problems. The sessions are strongly characterized by this short-term perspective; the intensity increases and attention is sharpened. The stance adopted by the therapist during die sessions is one of balancing a non-appraising, empathic and confirmatory listening aimed at making connections with reality and a faith in the patient's resources and capacity to maintain a sense of responsibility for their life; an approach which limits the patient's tendency to regress. Transference is not interpreted explicitly but is used by the therapist to understand the patient. Supervision is an important and essential component, whereby the therapist receives help in increasing understanding of that which is played out during the sessions and also of their own counter-transference. This understanding constitutes the foundation of the therapist's tentative formulations of that which is central in the patient's problems.     

‘The Ancient Cult of Madame’: when therapists trade curiosity for certainty

An experience in which the author followed his own objectives rather than the patient's, leading to a tragic end, is evoked as a frame for the presentation and discussion of a family treatment where the therapeutic process led by the therapist may have exceeded the needs and expectation of the family members. This is followed by a discussion about potential problems caused by a therapist's fascination for family stories, since its effects may be epistemologically discontinuous from, if not contradictory to, Cecchin's recommendation for ‘curiosity’ as a central dictum of the therapist's stance.     

A Sense of Orders

This paper provides an introduction to some of the basic concepts of the provocative French psychoanalyst Jacques Lacan. It illustrates the ways in which these concepts color the therapist's understanding of the patient as the therapist's attention is guided by the patient's expressions of thought and feeling. The response of the therapist is motivated by the interface which develops between this understanding and theoretical underpinnings. Clinical vignettes illustrating Lacan's mirror stage and his three basic orders, the Real, the Imaginary, and the Symbolic punctuate the explanations of these concepts. The paper weaves observations on the signification of language with examples of clinical interpretations.     

Therapeutic moments are the key: foster children give clues to their past experience of infant trauma and neglect

Foster parents often despair over the lack of information about the past experience of the children in their care, particularly with children who have experienced infant trauma and neglect. In the context of family therapy these unknowns pose both a challenge and an opportunity. The author proposes that foster children gives clues to their past experiences in therapeutic moments, which the therapist may recognize as a result of her own inner conversation. In conjunction with a sound theoretical knowledge of infant trauma and neglect, these moments have the capacity to open a dialogue in the relationships between therapist, child and foster family. This dialogical process offers an opportunity for the child's past experience of infant trauma and neglect to be expressed in silence, and the foster parent's present experience to be heard in stillness, opening for them a way to go on beyond the family therapy sessions.     

Doing Our Work: Words,Deeds, and Presence

Group leadership is an art, with relational tools of words, deeds, and presence. We aim to take our groups to creative places that they—and we ourselves—have never been before. Something needs to happen, fresh experience needs to emerge that becomes relevant to the growth of the members, including the therapist. The therapist's work is done while we are also doing something else. It entails a dual focus, or “binocular vision,” directed to personal discovery, while also focused on the group’s realities and growth potentials. Three case examples illustrate how the work happens to us: we evolve as a person as we do the work.     

Addressing the Person of the Therapist in Supervision: The Therapist's Inner Conversation Method

In this study a method of retrospective case supervision is presented aimed at helping the supervisee to become a better self‐supervisor. The method pays special attention to the therapist's self‐reflection and has the therapist's inner conversation as a central concept. The starting point of the method is an assignment in which the supervisee reflects on a case using a tape‐assisted recall procedure. The method helps trainees to develop experiential expertise to become more flexible and effective therapists. A case example of one training group of novice family therapists illustrates the use of the method.     

A therapist's use of verbal response categories in engagement and nonengagement interviews

Client return for post-intake therapy is one indication of client engagement in the therapy process. A therapist's verbal responses from seven engagement and four nonengagement interviews were classified using the 12-category Hill Therapist Verbal Response Category System (Hill, 1993). In engagement interviews, the therapist provided the client with more information than in nonengagement interviews. Therapist information utterances increased and therapist use of questions decreased throughout engagement sessions. In nonengagement interviews, therapist information declined and therapist questions increased during the sessions. Results suggest that clients returned for further therapy after intake when their problems had been clarified through the use of questions and work on the problems had begun with the therapist providing information.     

Reply to Panel Follow-up Questions

When both therapist and client share a traumatic event, there are multiple levels of vulnerability to traumatization for the therapist. Our personal vulnerability is not only a backdrop for our clinical work but also an acknowledged fact in many therapeutic relationships, a situation that changes the frame of the work. In addition to clinical challenges, shared trauma increases a therapist's vulnerability to vicarious traumatization; VT is defined as the negative transformation of the therapist's inner experience as a result of his or her empathic engagement with and responsibility for a traumatized client. Emphasizing the importance of awareness, self-care, meaning, and community, the article summarizes important steps to anticipate, address, and transform the therapist's experience of vicarious traumatization.     

Transcending a Differend: Studying Therapeutic Processes Conversationally

Studies of actual conversational behaviours used to generate positive change in family therapy are relatively rare. In this study such conversational details were examined as they occurred in a single session of family therapy. With passages identified by family members as helpful, discursive methods of analysis (conversation analysis and critical discourse analysis) were used to examine an actual conversation between a renowned family therapist (Karl Tomm) and a family formerly at a conversational impasse. Conversational practices and sequences in talk used by the therapist and family members to bridge these differences in their ways of relating are discussed.     

Studying the process of psychoanalytic parent–infant psychotherapy: Embodied and discursive aspects

This paper presents findings from an intensive, mixed methods case study of one session of psychoanalytic parent–infant psychotherapy (PPIP) addressing early relational trauma, and aims to shed light on the multimodal interactive processes that take place in the moment-to-moment exchanges comprising the therapeutic encounter. Different research methods were used on video material from PPIP sessions, including microanalysis of adult–infant interactions, discourse analysis of talk, and coding systems developed to study parent–infant interaction. These different perspectives were brought together with the clinical narrative to illuminate the complex, dynamic processes of parent–infant–therapist interaction. More specifically, the detailed analysis of one interactive episode revealed brief behavioral manifestations of fearful and disoriented states of mind, reflecting dysregulated interaction between mother and infant, which also powerfully affected the therapist. The processes through which the therapist gradually resolves this rupture are also described in detail. Through this pilot study, we were able to show that it is possible to systematically study the process of PPIP. The study contributes to the growing psychotherapy research literature that takes into account both the verbal domain and implicit, interactional processes in therapeutic practice, and underscores the therapist's comprehensive engagement in the therapeutic process.     

An Auto‐Ethnographic Study of “Open Dialogue”: The Illumination of Snow

This auto‐ethnographic study describes the changes in the author's thinking and clinical work connected to her first‐hand experience of Open Dialogue, which is an innovative, psychosocial approach to severe psychiatric crises developed in Tornio, Finland. In charting this trajectory, there is an emphasis on three interrelated themes: the micropolitics of U.S. managed mental health care; the practice of “dialogicality” in Open Dialogue; and the historical, cultural, and scientific shifts that are encouraging the adaptation of Open Dialogue in the United States. The work of Gregory Bateson provides a conceptual framework that makes sense of the author's experience and the larger trends. The study portrays and underscores how family and network practices are essential to responding to psychiatric crises and should not be abandoned in favor of a reductionist, biomedical model.     

“She is Just Not an Open Person.”: A Linguistic Analysis of a Restructuring Intervention in Family Therapy

A short exchange from a family therapy treatment with a couple is analyzed in detail according to what the speakers, in this case husband and therapist, do with each other and with the third participant, the wife, in making their utterances. They are seen to be performing a number of different acts with each utterance and an attempt is made to connect these acts with the actual linguistic properties of the utterances used; in this connection the semantic-pragmatic function of the operator, “just,” in one particular reading is discussed. These acts receive further support when the wider linguistic and situational context is considered. The exchange is of linguistic interest because the response of the therapist to the husband seems to be a non sequitur. It is shown, however, that pragmatic coherence, i.e., coherence with respect to the sequence of linguistic acts and moves between the speakers in the given situation, forces an interpretation of the two utterances as a connected text. The exchange is interesting therapeutically because the therapist's intervention brings immediate change in the husband. This striking therapeutic effect is attributed to the restructuring character of the intervention which sufficiently shifts the balance in the relationship between husband and wife. An analysis of the linguistic properties of the therapist's utterance shows that the restructuring is achieved by particular syntactic, semantic and pragmatic features of the utterance. It turns out that restructuring, as manipulative as it may appear on the surface, is a highly complex, sophisticated and powerful technique. It is not peculiar to family therapy; comparable procedures can be found in other forms of psychotherapy, e.g., psychoanalysis and client-centered therapy, and in general in everyday conversation situations where it is necessary for one speaker to get another speaker to modify what he is saying and to adopt a different view.     

Sequential analysis as a method of feedback for family therapy process

Abstract

The purpose of this study was to examine the relationship between therapist verbal behavior and family cooperation and resistance during the second session of family therapy with juvenile delinquents. Sequential analysis was used to investigate the impact of one therapist's behavior on family resistance and cooperation in a sample of 12 families. The results of the sequential analysis revealed that therapist “support” and “teach” behaviors were associated with significant increases in the likelihood of family cooperation. The study provides an example of how sequential analysis can be used to inform family therapists about the impact of their behavior on families.     

Hearing Metaphor: An Approach to Working with Family-Generated Metaphor

This article presents a step-by-step approach to working with family-generated metaphor in family therapy. Although the use of therapist-generated “therapeutic metaphors” has been widely advocated and practiced for many years now, less attention has been paid to the metaphors used by family members. We argue that the family's metaphors are a neglected linguistic resource in family therapy. Highlighting and validating these metaphors produces a therapeutic conversation in which the voices of family members are heard more clearly by the therapist, and the families' own imaginative energies are engaged in defining and pursuing the goals of therapy. Several case examples illustrate the use of this approach with children of various ages.     

Overcoming My Model of Goodness as a Psychotherapist

Summary

The case of Tina is presented to examine one therapist's countertransference issues with a female client who had features of a Borderline Personality Disorder. The therapist's emotional reactions to this client's raw expression of anger and frustration are explored. The discussion also emphasizes the struggle of the therapist in resolving her discomfort with this client and in setting therapeutic boundaries.     

A slow unfolding – at double speed: reflections on ways of working with parents and their young children within the Tavistock clinic's under fives service

This paper describes clinical work carried out as part of the Tavistock Clinic Under Fives Service, which offers brief focused psychoanalytically based interventions to families with young children, as well as longer-term work. It elaborates psychoanalyst Annette Watillon's idea that it is the dramatic way in which children enact their (and their family's) predicament in the consulting room which speeds up the process of change. The author clusters clinical cases into three categories, each cluster representing a different kind of ‘dramatic’ enactment and leading to a different kind of intervention relating to the therapist's role, the structure of the interventions and the ‘ports of entry’ for the work. The categories are defined as: ‘child-led drama’ with the therapist in the role of ‘therapeutic observer’; ‘internal parental drama’ with the therapist in the role of ‘therapeutic consultant’; and ‘external parental drama’ with the therapist in the role of ‘therapeutic modulator’. The author defines these categories, illustrating each category with clinical examples.     

A woman under the influence: An example of multiple victimization within a family

Abstract

The interactional processes depicted in rich detail in A WOMAN UNDER THE INFLUENCE are examined from a family therapist's viewpoint. Rather than portraying the persecution of a single individual by other members of the family, the film's drama demonstrates that the complex interactions within the extended family victimizes all the participants. When events are examined closely, it becomes clear that even the overt victimizers in the family system suffer as a result of the very processes in which they engage. The discussion of the film underscores the need for the therapist to empathize with all members of a dysfunctional system, especially when one member appears to be the victim.     

Warriors,authors and baseball coaches: the meaning of metaphor in theories of family therapy

This article examines the metaphors family therapists use in their theories to reveal aspects of the theories which are not explicitly stated, using Whitaker's symbolic experiential therapy, Minuchin's structural therapy and White's narrative therapy as examples. Such examination, drawing on social constructivist understandings of metaphor and meaning making, reveals that Minuchin's metaphors of family as organism and therapist as artist and warrior emphasize the family as relatively holistic and the therapist as relatively interventionist. In contrast, Whitaker's metaphor of family as ecological system or team and therapist as coach emphasizes the interdependence and context sensitivity of the family and relative powerlessness of the therapist to impose change. Finally, White, reflecting his explicitly post‐structural commitment, uses the metaphor of therapy as a journey undertaken with a map and as therapy as an act of re‐narrating a story.