When Suicide Is at Stake: Some Thoughts on the Therapeutic Space between Therapists and Adolescents

Looking at adolescence as a period of turmoil as well as abrupt physical and mental changes, it is not surprising that in western countries suicide is the primary cause of death in adolescents and young adults ages 15–24. Most therapists treating adolescents encounter patients who frequently engage in suicidal behavior. This significantly challenges the therapeutic bond and influences the therapeutic space in a unique way. In this article, we address the challenges specific to the therapeutic alliance in treating adolescents presenting suicidal behaviors. While literature on the nature of the therapeutic bond with adult suicide attempters is available, literature on the distinguishing characteristics of the therapeutic bond with adolescent attempters is lacking. Two vignettes are presented to illustrate this distinctive alliance.     

The therapeutic and working alliances

Since their introduction, the concepts of the therapeutic alliance and the working alliance have provoked debate regarding the nature and function of these alliances and the applicability and validity of the concepts. Features of these concepts as originally put forth by Zetzel and Greenson, respectively, are delineated, with emphasis on the significant distinctions between them. Their relation to degree of psychopathology is examined, especially with respect to what may be understood as the more "silent" aspects of the therapeutic alliance. Mutual identification, empathy, and role-responsiveness are stressed as constituent features of the therapeutic alliance, with the working alliance seen as possible (theoretically and clinically) only after a therapeutic alliance has to some degree been established. Both alliances are understood as intrinsic structures within the analytic process, and illustrative case material is presented.     

A Social Constructionist Model of Therapeutic Factors

Evidentiary support for the efficacy of therapeutic models has been a contentious issue since the professionalization of psychology. Despite advances in evidence-based practices in psychology and common factors research, discontent still exists among postmodern psychotherapists in that evidence is mainly defined in modernist/positivistic terms, thereby excluding therapeutic models based on alternative nonpositivistic epistemologies. I proposes a model, which is based on social constructionist theories, for investigating the therapeutic efficacy of various approaches. This article evaluates and differentiates between two models for viewing the efficacy of psychotherapy, namely outcome versus process efficacy. A social constructionist model of therapeutic factors is proposed as a means to incorporate therapeutic factors into psychotherapy processes that are consistent with a social constructionist theory of change. Three main therapeutic elements, which are identified as central to an effective psychotherapy process, are outlined in the model. The proposed model may be useful as a guide to efficacious psychotherapy and as a means for investigating the efficacy of social constructionist therapies.     

乳腺癌的现代与传统治疗模式的比较分析与思考

乳腺癌是女性最常见的恶性肿瘤之一,现代治疗模式已经广泛应用于临床。近年来,随着循证医学和基因相关技术及生物信息技术的不断发展,乳腺癌治疗方法得到不断改进,但远没有达到系统化、个体化、最优化的治疗目的。因此,现有的治疗模式值得我们去深思,并从哲学意义上探索更为完善的治疗模式。     

Hausaufgaben in der Psychotherapie

Homework assignments represent a standard intervention in psychotherapy. Homework provides the unique opportunity to emphasize patients’ responsibility for therapeutic change and to intensify the therapeutic process. Despite these high potentials systematic homework assignment is still rare in practice. Psychotherapy research has just recently focused its attention on homework as an effective therapeutic method. Meanwhile the positive effects of homework use on therapeutic outcome have been demonstrated but little is known about therapeutic strategies to enhance these effects. The present article highlights the functions of homework within the therapeutic process and discusses its theoretical mechanisms of action. The article concludes with suggestions from both an empirical and practical point of view to further assist practitioners’ use of homework assignments.     

Therapeutic Relationship

This article addresses the important role of the therapeutic relationship in cognitive-behavioral therapy (CBT). As has been noted from the inception of CBT, there are critical features of both the therapist and the relationship that optimize the likelihood of therapeutic success, and this article briefly describes these features. It is further argued that a successful therapeutic relationship in CBT is not static but is flexible and adaptive both across and within clients, as their needs and concerns vary. A positive therapeutic relationship is viewed within CBT as a necessary but insufficient condition for change, as the relationship serves as a foundation upon which interventions are scaffolded, but that the client’s response to various interventions itself shapes the interactions between therapist and client. Finally, it is argued that the key therapeutic ingredients of CBT are largely teachable, and the article provides several suggestions to promote an effective therapeutic relationship in CBT.     

Quelle place pour les médiations thérapeutiques dans la « psychothérapie par l'institution » ?

Therapeutic mediations are an essential part of the communautary treatment offered by our Clinic (Clinique Dupre de Sceaux). They contribute to the adaptation of our therapeutic program to the psychopathological characteristics of our adolescents and young adults patients. We see this therapeutic mediations as a tool to allow a bounding between the treating team and patients whose central psychopathological feature is the fear of bounding and relationship with significative others seen as potential threat of dependency and/or seduction. Through therapeutic mediations, the treating staff is able to deal with repetitive symptomatic situations, using the empathic capacity of each member of the team included in the “psychic enlarged space” of the patient. Therapeutic mediations are the contributing to regulate the bounding process in this type of patient. Through a clinical presentation this paper will present the use of therapeutic mediations in our Clinic. We will then discuss more widely the concept of “psychotherapy through the institution” we use in this type of therapeutic setting.     

The therapeutic alliance in couples therapy: clinical considerations

This article presents clinical considerations about the therapeutic alliance in couples therapy, stimulated by pertinent new research findings reported in this issue. A loyalty dimension of the couple's relationship is described, as well as its influence on the therapeutic alliance in couples therapy. The therapist's establishment of a "meta-alliance" with the couple around their loyalty conflicts, avoidance of splits and disruptions, and prioritization of marital distress (versus individual symptoms) as the primary focus of treatment all serve to solidify the therapeutic alliance. In addition, identifying the partners' early family-of-origin distress can help predict and respond to strains in the therapeutic alliance that may occur later in therapy. Finally, the therapist helping the couple to balance their relational power differences in therapy and to address their concerns about the impact of the therapist's gender also strengthens their therapeutic alliance. A clinical case and vignettes are included to illustrate these issues.     

Applying the law therapeutically

Therapeutic jurisprudence is the study of the law as a therapeutic agent. Although much of therapeutic jurisprudence focuses on possible changes to the law, one important interdisciplinary dimension of the endeavor involves the therapeutic application of existing law. Examples are provided of therapeutic application of existing law, and this exercise is proposed as a promising path for applied psychology.     

Commentary on Stirling Moorey's and Janet Feigenbaum's papers

Our notions of what constitutes a good therapeutic relationship come from models developed for people with high levels of personal resources who actively choose therapy in preference to other ways of addressing their problems. The context is quite different for those with more severe and enduring mental health problems, when therapy can be one of many interventions being provided. Some of the dilemmas that arise within the therapeutic relationship in such cases can be understood in terms of the therapeutic relationship being conceived of within the dynamics of a dyad, when the actual situation is more akin to a triadic relationship comprising the client, the therapist and others involved in the client's care. Examples of threats to the therapeutic alliance, which I encounter quite frequently in my work, are explored from the perspective of the therapeutic couple within three-person space, as well as from the perspective of the differing, and sometimes conflicting, functions of mental health care. The implications of this for the provision of psychological therapy for people with severe mental health problems within the NHS are then considered.     

Factors Associated with Therapeutic Approaches Among Norwegian Occupational Therapists: An Exploratory Study

According to the Intentional Relationship Model, the use of therapeutic approaches tailored to individual clients’ needs is essential for building therapeutic relationships. This study investigated factors associated with occupational therapists’ preferred therapeutic approaches. One hundred eight occupational therapists were recruited as a convenience sample, and the data were analyzed with linear regressions. Mental health as the field of practice was associated with a stronger preference for use of empathy. More job satisfaction was associated with stronger preference for the instructing mode. Empathy appears to be more commonly used in mental health practice, whereas instructing may be linked with job satisfaction.     

The future of psychotherapeutic environments: Learning from experience at a Swedish therapeutic community

Ten years' experience in a Swedish therapeutic community outside the organisation and culture of the psychiatric services is summarised with reference to a longitudinal prospective study. This therapeutic environment proved to be better suited to patients' needs, and the organisation and setting were more in accord with the treatment philosophy than at other units with which it was compared. It was possible to identify different phases in the history of the therapeutic community and the development of patients. The patient group as a whole have shown improvement in psychiatric terms, as well as with regard to psychosocial interpersonal and emotional functioning. The more lasting personality traits have not, however, altered. Difficulties in the work, and obstacles to change, appeared to derive from: the therapists' tendency to disregard problems in the relationship; not enough work focused on separation and negative, hostile feelings. Termination of treatment was a strain which the patients found difficult to manage. The period subsequent to the stay at the therapeutic community was decisive for the long-term outcome. Today, it is necessary to amend our concepts of a decisive and complete cure.     

Catathymic image experience as a psychotherapeutic imagination procedure--principles and practical approach

The catathyme image experience conceived by Leuner is introduced as a psychotherapeutic imagination method structured into many standard motives. The general basic principles, the so-called direction principles as well as the special therapeutic techniques of the day dream technique mainly recommended as a short time therapy are explained. Further information on the use of the symbol drama in groups and the indication finding is given. Modification and combination opportunities with other psycho therapeutic methods is referred to.     

Interaction Testing as a Measure of Therapeutic Change in Groups

Two therapy groups were followed by means of repeated interaction testing over the course of their therapeutic lifetime. The consensus Rorschach, analyzed as if it were the product of a single individual, indicated marked differences in the progress of the two groups with evidence of growth, expansion in the case of one group and a therapeutic stalemate in the case of the second group. Independent clinical evaluation of therapeutic progress by the therapists of both groups were in complete agreement with the consensus Rorschach psychograms. The possibility that non-conformist members may contribute to poor therapeutic progress is considered.     

Sculpting Present and Future: A Systemic Intervention Model Applied to Psychosomatic Families

We present a therapeutic intervention model for use with psychosomatic families. This method, the result of our extensive research on various psychosomatic disorders, uses family sculptures of the "present" and "future": each family member is requested to represent the family as it now "is," and how it "will be" in the future. We discuss the theoretical reasons for our choice of this method: (a) the opportunity to use a therapeutic language that is similar to the nonverbal language of the psychosomatic symptom, and (b) the usefulness of reinserting temporal dimensions into family systems that seem to have lost their evolutionary potential and to be in a sort of "time lock." Two clinical cases are discussed (a child with chronic asthma and an anorexic adolescent); the use of sculptures in both cases revealed the underlying problems and made positive therapeutic interventions possible. Finally, we point out how the use of sculpture as a therapeutic technique enables therapists to deal with multiple systemic levels.     

Schematherapie bei antisozialem Verhalten und Psychopathie

In the Netherlands schema therapy is the first evidence-based treatment to be recommended for patients with personality disorders in forensic settings. Initial results show that schema therapy can even be effective in cases of “psychopathy”. The central concept in schema therapy are schema modes which can also be seen as emotional states or “parts of the personality”, which dominate temporary thoughts, emotions and behavior. Schema modes are the basis of individual mode models, which guide understanding and treatment of the disorder throughout the complete therapy. The schema therapeutic analysis of delinquency is part of the schema mode model and connects the sequences of the crime with the offender’s schema modes. With respect to the mode treatment, emotion-focused techniques and the therapeutic relationship are of special importance. The schema therapeutic treatment plan combines short-term behavior-related therapeutic goals with the underlying themes (needs and modes) in order to plan concrete interventions based on this. This has to be embedded into the individual structure of therapeutic options in the respective institutions (e.?g. individual psychotherapy, nursing staff, occupational therapy). This article demonstrates the practice of the schema therapeutic approach with a forensic case study and discusses resources and limits of the schema therapeutic approach in a forensic setting.     

The dynamics of empirically derived factors in the therapeutic relationship

The therapeutic relationship is the source of major concepts in psychoanalytic clinical theory. Such concepts as resistance, transference, countertransference, and the alliance are fundamental, even though there may be shifts in meaning between theoretical schools and clinical contexts. In the clinical psychoanalytic literature, disagreement exists over the nature of the alliance and its essential components. Empirical studies using reliable patient, therapist, and observer scales to assess the alliance demonstrate a correlation with psychotherapeutic gains. In the study reported here, thirteen patients were followed for 6 to 33 months of psychodynamic psychotherapy, during which time their views of the therapeutic relationship were assessed, and several experiential measures taken, all on a weekly basis. Statistical analyses reveal that the therapeutic relationship, as reflected in the patients' weekly responses to the St. Louis Therapeutic Relationship Rating Scale, has four distinct components: therapeutic alliance, resistance, transference love, and negative transference. On a week-by-week basis, the therapeutic alliance was the strongest predictor of improvement in patient-reported general adjustment, as reflected in such areas as self-esteem, positive affect, social relations, work productivity, satisfaction, and optimism. Time plots of the variables show the typical time course for the components of the therapeutic relationship, as well as for improvement on the experiential variables. Results indicate that the therapeutic alliance, transference, and resistance are central components of the psychotherapeutic relationship, which in turn predict the ongoing life experience of the patient.