Psychoanalytic aspects of inpatient treatment

This paper looks at the experience of inpatient hospital treatment at the Cassel Hospital and how formal psychoanalytic psychotherapy, with its emphasis on the transference and the inner world, fits into that context and orientates itself to some of the realities of the setting. It outlines how psychotherapy and nursing can work to inform and enrich each other, and what is psychoanalytic about the overall work. A bridge of understanding is built using the patients' perceptions of, adjustment to and conflict about the inpatient setting, and the affective impact of the processes on patients and staff alike. Two clinical examples of severe child abuse family cases are given, the first of Munchhausen syndrome by proxy, the second in which a baby sibling had been killed. They show how in-depth psychoanalytic work with mother and child and individual psychotherapy of the child can be combined with psychotherapy of the parents and intensive work in the therapeutic community. Such a combination can contribute, even in cases of severe pathology, to the development of the relationship between mother and child and promote successful rehabilitation in the outside community.     

Pitfalls in the psychoeducational assessment of adolescents with learning and school adjustment problems

Over the past decade there has been a growing interest on the part of educators, medical specialists, mental health personnel, and the lay public in the diagnosis, evaluation, and remediation of specific learning disabilities in the school-age child. This paper attempts to show through case illustrations of five high school-age adolescents how parents can seek from clinical evaluators a diagnostic impression of primary learning disability for their nonlearning disabled children; how this otherwise legitimate diagnostic category can be inappropriately used in the service of denying the salient individual, emotional, and family system factors at work in the school-related difficulties; and how the label of learning disability can work as a formidable resistance on the part of the family when, following comprehensive, in-depth assessment, professional recommendations focus less on specific educational remediation and more on the need for individual or family psychotherapy. Suggestions are made for dealing with this clinical issue.     

Revisiting ‘What works for whom?’: A qualitative framework for evaluating clinical effectiveness in child psychotherapy

This paper describes a framework for evaluating the effectiveness of child psychotherapy used by child psychotherapists in an inner city Child and Adolescent Mental Health Service (CAMHS). The Hopes and Expectations for Treatment Approach (HETA) involves using the assessment for psychotherapy that normally precedes treatment to derive a baseline from which to generate a set of hopes/expectations as regards the effects of the treatment on the part of parents and the psychotherapist, to be revisited one year after the start of the psychotherapy and/or at its completion. The Strength and Difficulties Questionnaire, for parents and schools, was also administered before and after the treatment. The characteristics of the first 30 children referred for psychotherapy over a particular time period are described. Of the first 15 children in this group to complete one year of individual psychotherapy, all showed change or significant change in the areas concerning parents' and therapists' hopes at the end-of-year review, as rated by parents and psychotherapists. A case of a child with conduct disorder is used to describe how the assessment generated a psychoanalytic formulation, how the therapist's understanding was fed back to the parents, and how the parents' and therapist's hopes and expectations were derived and recorded. This case illustrates powerfully the impact of trauma in the parents' backgrounds on the internal world of the child, and how the method provides a useful bridge between parent and child work. Feedback from the psychotherapists, the parents and the referrers using the framework is reviewed, and in conclusion the paper argues for the framework's value in promoting good practice in the treatment and management of complex cases and in enhancing awareness of the nature and scope of the psychotherapy process.     

Use of a reference group in researching children’s views of psychotherapy in Malta

This paper explores the process and outcomes of a children’s reference group within the context of child psychotherapy research in residential care. The reference group was set up to consult children about the design of a research project which seeks to evoke, represent and understand children’s views of psychotherapy. No work to date has explored the experience of reference groups in the context of child psychotherapy in residential care in Malta. The paper contextualises the research within the literature on reference groups in child research, which identifies the potential of reference groups as a participative and co-reflexive activity which can inform research design. The paper critically examines the nature and conduct of the reference group by acknowledging the specific context of this work rather than assuming this is necessarily positive. It does so by specifying and evaluating the outcomes of the reference group in line with its aims. The paper draws on the recordings of the reference group meetings and reference group field notes taken by the researcher as key data which were thematically analysed. The main outcomes of the reference group include children’s contribution to the design of data collection methods especially in terms of not relying only on words during data collection. Children also identified key ethical issues from the point of view of young psychotherapy service users, especially in relation to issues of trust within a residential care context. Children also reviewed and appraised research information material. The reference group process drew from the researcher’s and participants’ contexts and contributed significantly to the researcher’s reflexive process especially in terms of acknowledging his power and positioning as an adult and his dual role as a practitioner/researcher.     

Psychoanalytic psychotherapy in paediatric liaison: a diagnostic and therapeutic tool

Paediatric liaison work requires an appreciation of the interweaving of the different factors involved when a child has physical symptoms. Psychoanalytic psychotherapy is usually viewed simply as a potential treatment option. This paper argues that its use is both therapeutic and diagnostic and that it should be valued for this breadth of contribution. The therapeutic process is conducted in a way that can promote an understanding of the child and their context and thus enhance the ability 9 to meet the child's needs by all involved in their care. This can be achieved without sacrificing the degree of privacy that the psychotherapist/patient relationship requires. Material is presented from the psychotherapy of a child who had an hereditary condition which moved unexpectedly into a terminal 2 phase after psychotherapy was started. Examples are given to illustrate the importance of the understanding gained from therapy and how, through an integrative process, it was used to assist the overall 4 care. The material also describes the potential diagnostic use of information from psychotherapy when this is formulated by consideration of conscious and unconscious mechanisms alongside mental state phenomenology. This has implications for the relationships between disciplines and for their training requirements.     

Time's wingèd chariot: Short-term psychotherapy in later life

Abstract

This paper is concerned with the appropriateness of short-term psychodynamic psychotherapy with older adults, a client group which has historically been neglected in psychotherapeutic practice. Drawing on the case study of a fourteen-session therapy with a woman in her seventies, it is argued that brief exploratory work can be of particular value to people nearing the end of their lives. The nearness of death gives a special urgency and motivation to the work and a time-limited therapeutic contract mirrors the reality of having only a short time left. Making psychotherapy available to older people also represents an important valuing and validation of their experience.     

Transference and countertransference in an applied setting — education

This paper offers an overview of current clinical approaches to psychoanalytically informed work with parents by child psychotherapists. The analysis is based on practice at the Tavistock Clinic and on broader knowledge of trends in work with children and families within the National Health Service. A brief history sets the scene. Four varieties of approach are described, with clinical examples. The particular sensitivity of child psychotherapists to infantile features in the personality is highlighted, and it is argued that this, together with their broad clinical experience, provides a proper basis for psychoanalytic psychotherapy with parents. Such work significantly extends and enriches the clinical contribution of child psychotherapists and has involved a shift in professional identity. It also raises ethical issues which are discussed.     

What is this thing called love? Desire,psychotherapy and Plato’s symposium

The platonic dialogue, Symposium, is approached here through client work. This rich and complex text is not rushed through as if the point of a conversation must be its swift and clear termination, rather than how potentially fruitful, generative and transformative it is or may come to be when we reflect or engage in further conversation. This paper suggests that Symposium presents us with two ways of thinking about relating to another, and ends with some remarks about this platonic dialogue and psychotherapy that could, of course, be followed by more conversation.     

A naturalistic study of the effectiveness of time-limited counselling with low-income clients

The role of counselling and psychotherapy services in relation to the needs of economically disadvantaged individuals has been largely neglected in the recent research literature. Although a small number of theoretical papers and case analyses have been published, there is an absence of studies that examine the effectiveness of counselling with this client group. The present paper reports on a naturalistic outcome study of the effectiveness of time-limited counselling (seven sessions) with low-income clients. Analysis of pre-counselling, postcounselling and follow-up measures of mental health and problem ratings indicated levels of change equivalent to those achieved in controlled studies of counselling and psychotherapy with other client groups. Factors influencing the effectiveness of counselling included gender and employment status. Qualitative client reports suggested that the main benefits experienced by clients were in the areas of self-understanding and self-belief. For illustrative purposes, data from low-income clients are compared with results from employee counselling clients receiving a similar service. The implications of these findings for further research are discussed.     

Microphenomena research,intersubjectivity and client as self-healer

This article describes an approach to counselling and psychotherapy which complements dominant discourse approaches to clinical evaluation based on New Public Management systems which underpin the Improved Access to Psychological Therapies scheme within the field of therapy. It is based on an approach to research and practice development which I will call practitioner microphenomena research. In order to demonstrate the method, I will examine an extract from a single case study of a client with major depressive disorder from the point of view of intersubjective theory and a little-known approach to therapy called anthroposophic psychotherapy based on the work of Rudolf Steiner. I will show how the two clinical methods are well suited to examining the microphenomena of practice and can be integrated into a coherent whole. A central feature of the account will be the anthroposophical view about the central importance of our individuality or ‘I’ which has similarities with the Jungian self but is still distinct from it.     

Psychotherapy: Definitions, Mechanisms of Action, and Relationship to Etiological Models

In this paper, we define psychotherapy as a modality of treatment in which the therapist and patient(s) work together to ameliorate psychopathologic conditions and functional impairment through focus on the therapeutic relationship; the patient's attitudes, thoughts, affect, and behavior; and social context and development. The possible mechanisms of action and active ingredients of psychotherapy in children and adolescents are discussed, with an emphasis on the above-noted domains. The adult psychotherapy literature strongly supports the central roles of the therapeutic relationship and therapeutic empathy; this has been much less intensively explored in the child and adolescent psychotherapy literature. Similarly, there have been few studies examining the mediation of treatment effects by impact on specific domains. Ideally, treatment studies should gather data that can be informative about the impact of putative mediating and moderating psychosocial and biological variables on outcome and course. The results of such studies can aid further refinements in both theories of etiology and improvement in treatments for children and adolescents.     

Group work in general practice

In this article, consideration is given to a problem often experienced in relation to courses offering psychodynamic understanding to front-line workers with troubled clients – the complexity for the student in taking the learning ‘home’ in a productive manner and the potential isolation of the student in, or alienation from, their workplace. A model of course delivery is described in which an active three-way partnership between student, course and workplace is fostered which enhances the students' learning, enables the workplace to benefit more fully from the course and enhances the effectiveness of the course in improving service to the ultimate client – the service user.     

Hidden in Plain Sight: The Active Ingredients of Executive Coaching

We propose that I/O psychologists who coach executives have overlooked psychotherapy outcome research as a source of information and ideas that can be used to improve our executive coaching practices. This research, based on thousands of studies and many meta-analyses, has converged on the conclusion that four "active ingredients" account for most of the variance in psychotherapy outcomes. We describe how this literature has identified four primary "active ingredients" that account for most of the variance in psychotherapy outcomes: 1) Client/extratherapeutic factors (40%), 2) The relationship or alliance (30%), 3) Placebo or hope (15%), and 4) Theory and technique (15%). Working on the assumption that psychotherapy and executive coaching are sufficiently similar to justify generalization from one domain to the other, we describe these four active ingredients at length and explore how they may be at work in the executive coaching process. We also suggest that I/O psychologists have training and experience that allows us to leverage some of these active ingredients in our executive coaching (e.g., understanding of client individual differences related to coaching outcomes). But we also have areas of weakness (e.g., building a strong working relationship with an individual client) that may need to be bolstered with additional training and development experiences.     

Constructivist psychology of child abuse and implications for psychotherapy

Abstract

This paper reviews constructivist and related literature on child abuse and psychotherapy. Constructivist psychology, with its emphasis on the personal, socially embedded construction of meaning, is uniquely situated to contribute to humanistic psychotherapy for child victims and adult survivors. Conversely, work with abused clients deepens our understanding of developmental meaning‐making processes and the social ecologies of meaning within which they unfold.

Constructivist approaches to child abuse are inherently humanistic, focusing on the child victim's and adult survivor's attempts to make meaning of their experiences, including the often traumatic experiences of abuse and the relational contexts in which it occurs. This paper first discusses how constructivist psychology may deepen our understanding of the impact of abusive experiences, the reverberation of those experiences through subsequent living, and the role of constructivist therapies in the healing process. Secondly, this paper explores reflexive aspects of work with abuse survivors that may challenge our cultural and professional assumptions and deepen our commitment to constructivist, humanistic, and feminist psychotherapies.     

Benefits and Challenges of Conducting Psychotherapy by Telephone

Telephone-delivered psychotherapy has increased utility as a method of service delivery in the current world, where a number of barriers, including economic hardships and limited access to care, may prevent people from receiving the treatment they need. This method of service provision is practical and has the potential to reach large numbers of underserved people in a cost-effective manner. The aim of this paper is to review the state-of-the-art of telephone-delivered psychotherapy and to identify improvements and possible solutions to challenges. Results of randomized controlled trials indicate high client acceptance and positive outcomes with this method of delivering psychotherapy. Nonetheless, psychotherapists wishing to deliver psychotherapy by telephone face a number of challenges, including a lack of control over the environment, potential compromises of privacy and confidentiality, developing therapeutic alliance without face-to-face contact, ethical and legal issues in providing psychotherapy by telephone, handling crisis situations at a distance, and psychotherapist adjustment to conducting psychotherapy in an alternative manner. There remains a need for further research, including direct comparisons of face-to-face psychotherapy with telephone-delivered psychotherapy and feasibility of telephone delivery of psychotherapies other than cognitive behavioral therapy.     

Audit in psychoanalytic psychotherapy with children and adolescents

The importance of multidisciplinary audit in child and adolescent psychiatry, including the work of child psychotherapists, is discussed. Research is highlighted which shows that certain groups of children in particular benefit from psychoanalytic psychotherapy. The problems related to auditing psychoanalytic psychotherapy are discussed, and a possible method of audit based on peer review of notes, which takes into account both inner and outer change, is presented.

A patient is discussed whose notes have been audited using the audit form. It is suggested that this form of audit has good educational potential as well as ensuring a high standard of patient care.     

A developmental perspective on psychotherapy process, psychotherapists' expertise, and “Meaning-Making Conflict” within therapeutic relationships: Part II

Part I—A Dialectical-Constructivist View of Human Development, Psychotherapy, and the Dynamics of Meaning-Making Conflict Within Therapeutic Relationships-reviewed a dialectical-constructivist model of human development and articulated, in the language of that model, how psychotherapy, in general, works. It described and illustrated three generic processes which contribute to the frequent successes of an extremely diverse range of psychotherapy theories and practices. This view of psychotherapy focused on both the client's meaning-making processes and the therapist's meaning-making processes, and how they contribute together to effective psychotherapy. Part I also offered a way of understanding what is going on when therapeutic progress is blocked by conflict between the client's and the therapist's meaning-making processes. Part II—Dialectical, Thinking and Psychotherapeutic Expertise: Implications for Training Psychotherapists and Protecting Clients from ‘Theoretical Abuse’—explores those experiences in which the therapist's exercise of this or her own meaning-making structures, and maintenance of the integrity of his or her theories, has a limiting or destructive impact on the value of therapy to the client. It considers the concept of “theoretical abuse” by psychotherapists as a way of characterizing the most destructive of these experiences. This serves as a rhetorical device for introducing comparisons between these phenomena and the phenomena of sexual abuse by psychotherapists, in terms of dynamics, prevalence, and appropriate strategies for prevention. Part II uses work on the development of dialectical thinking in adulthood to conceptualize how different understandings of the nature of psychotherapists' theories and expertise increase or decrease the likelihood and severity of ‘theoretical abuse’. Finally, it derives implications for training psychologists and other psychotherapy professionals.     

A developmental perspective on psychotherapy process, psychotherapists' expertise, and “Meaning-Making Conflict” within therapeutic relationships: A two-part series

Part I (in this issue)—A Dialectical-Constructivist View of Human Development, Psychotherapy, and the Dynamics of Meaning-Making Conflict Within Therapeutic Relationships— reviews a dialectical-constructivist model of human development and articulates, in the language of that model, how psychotherapy, in general, works. It describes and illustrates three generic processes, which contribute to the frequent successes of an extremely diverse range of psychotherapy theories and practices. This view of psychotherapy focuses on both the client's meaning-making processes and the therapist's meaning-making processes and how they contribute together to effective psychotherapy. Part I also offers a way of understanding what is going on when therapeutic progress is blocked by conflict between the client's and the therapist's meaning-making processes. Part II—Dialectical Thinking and Psychotherapeutic Expertise: Implications for Training Psychotherapists and Protecting Clients from Theoretical Abuse—explores those experiences in which the therapist's own exercise of his or her meaning-making structures, and maintenance of the integrity of his or her theories, has a limiting or destructive impact on the value of therapy to the client. It considers the concept of “theoretical abuse” by psychotherapists as a way of characterizing the most destructive of these experiences. This serves as a rhetorical device for introducing comparisons between these phenomena and the phenomena of sexual abuse by psychotherapists, in terms of dynamics, prevalence, and appropriate strategies for prevention. Part II uses work on the development of dialectical thinking in adulthood to conceptualize how different understandings of the nature of psychotherapists' expertise increase or decrease the likelihood and severity of “theoretical abuse”. Finally, it derives implications for training psychologists and other psychotherapy professionals.