Winnicott's children: The holding environment and therapeutic communication in brief and non-intensive work

This paper discusses brief and non-intensive work using a Winnicottian framework for understanding the processes involved. The importance of play, communication and interpretation are considered within the careful establishment of a unique holding environment for each patient. Parallels are drawn with ordinary development and care of the infant and young child. Two clinical examples are given to illustrate these concepts. The first describes the treatment of parents and children following the accidental death of the youngest child, and the second describes time-limited work with a sexually abused and abusing teenage boy. The value of providing a range of psychoanalytic treatments to meet the range of needs of patients is discussed. The importance of conceptualizing such treatments in ways that do not imply that they are ‘diluted’ psychoanalysis is also stressed, particularly with a view to the increasing pressure on therapists to offer help to as many children as possible within limited treatment time.     

Therapist orientation,supervisor match,and therapeutic interventions: Implications for session quality in a psychotherapy training PRN

Background: Theoretical orientation is a multifaceted construct that is integral to the process of psychotherapy and psychotherapy training. While some research has been conducted on personal identification with particular schools of psychotherapy, techniques used in psychotherapy sessions, and match between trainees and supervisors in training, there is insufficient information regarding how these may interact with one another. Aim: This study, conducted in a practice research network of trainee therapists, was designed to test whether these variables may be related to one another in predicting session quality. Method: The sample comprised 328 sessions from 26 clients and 11 therapists, with the clients completing session quality measures and therapists completing measures of technique immediately post‐session. Results: Using multilevel linear modelling, the data showed varied results. For behavioural therapy and person‐centred therapy, techniques and orientation were unrelated to session quality in the sample. However, process‐experiential, psychodynamic, and cognitive therapy techniques were all involved in interactions with therapist and/or supervisor orientations. Conclusions: These results suggest that the impact of specific psychotherapy techniques sometimes depends on the orientation of the therapist and/or supervisor. For instance, sessions high in cognitive therapy techniques were only associated with positive outcome when both the therapist and supervisor were highly cognitively oriented. Though preliminary, these results suggest that orientation may be an important variable to consider in training and supervision, especially in the context of other variables.     

‘The essay method’ a qualitative method for studying therapeutic dialogues

ABSTRACT

This paper presents a qualitative research method for analysing therapeutic dialogues called ‘the essay method’. A central part of the method uses the format of the literary essay as a model. The method consists of a close monitoring of clinical material guided by an overall psychoanalytic/psychodynamic theoretical frame. It combines both clinical details and global patterns of clinical material and is especially fitted for studying relational qualities of psychotherapeutic dialogues. In this paper, the background for qualitative analysis in studying psychoanalytic material is discussed, and the procedures for using the method are demonstrated. A study of therapeutic competence in a group of student therapists is used as an example of the method in practice, demonstrating that the essay method may have potential for revising theory and establishing new concepts based on empirical findings. The essay method is compared with other qualitative methods, and it is argued that it is suitable for psychoanalytic research.     

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.     

From scapegoating to thinking and finding a home: delivering therapeutic work in schools

This paper discusses how the child psychotherapist's core skills can be usefully applied in a school setting. It outlines some of the important policy changes that have necessitated a move towards delivering therapeutic work in community settings such as schools. It is argued that the role of the child psychotherapist in schools has much in common with the role played by the psychotherapist in a therapeutic community. The paper suggests that therapy in schools is in many ways less simple than therapy in clinic settings, and in particular it is often unclear who exactly the client is and at what level to intervene when a referral is made. The referred patient is not necessarily the ‘problem’, so that the child psychotherapist must be prepared to tackle issues in the system to ensure that splitting and projection are reduced, and systems around children can become more containing. Clinical vignettes and one main clinical illustration are used to try to illustrate these points.     

Eternity in an hour: experiences of time related to psychotherapy sessions

In this paper I consider the individual nature of the way a person develops senses of time. I suggest that something of a patient's early, unvoiced, experience is revealed through the temporal rhythms of interaction with the therapist. I refer to development, cycles of experience, metabolism, transgenerational emotions, experiences of beginnings and endings, early interactions with (m)other, together with narrative and its relation to unconscious processes. Experiences of time within the session indicate the nature of the feelings that are being lived, or refused life. I consider the paradox of living in the present and its relation to chronology. Lastly I give an example of the difficulty of timing comments when there is no flow of feeling, which is, itself, a communication.     

The talking cure: Wittgenstein's therapeutic method for psychotherapy,by John M. Heaton

This paper offers an outline of the challenges particular to intersubjective approaches to psychoanalytic psychotherapy in South Africa. Past experiences of deeply entrenched and racialized divisions between communities continue to shape the negotiation of power in therapeutic spaces, and affect participants’ capacity to engage freely with the exploration of unconscious communication. Examples are given of the ways in which race, class and gender difference may complicate, hinder or enrich intersubjective psychoanalytic psychotherapy. Some suggestions are made about the kinds of reflective work that need to be undertaken by psychotherapists in order to assume fully the burdens of history and to appreciate fully the opportunities offered by a society in transformation.     

Beyond Ritalin: The importance of therapeutic work with parents and children diagnosed ADD/ADHD

It is estimated that as many as 5 million children in America are being medicated with psycho-stimulants for Attention Deficit Disorder (ADD) and/or Attention Deficit/Hyperactivity Disorder (ADHD). Parents frequently seek psychotherapy for their child up to one and a half years after medication has been tried due to a high degree of symptom recidivism. The parents should be engaged in the therapeutic work, if at all possible. An intricate web begins to unfold as the current parent-child relationship resonates with the parents' relationship with their own parents, siblings and childhood experiences. Working with the parents is essential if one is going to know anything about the cross-generational dynamics involved and if real and helpful change is going to occur. Conscious and unconscious parent—child dynamics of hyperactive behaviour in children are discussed. A clinical case illustration is described. Alternatives to medicating children are also described.     

Negotiating time: the significance of timing in ending inpatient work

This paper discusses work with young people during their stay on an NHS psychiatric inpatient unit, especially focusing on the end of treatment and the appropriate timing of discharge into the community. When approaching the end of an admission, various factors are considered that seem particularly relevant to the decision of when a young person may be ready to leave and cope with the transition back to life outside the unit. Indications of medical stability, in patients where this has been an issue, is a factor of prime importance. Other important factors include family functioning; the availability of adequate ongoing local CAMHS support for the child and family; suitable school provision; and the identity of the child within a peer group. The reality of NHS resources and the demand for inpatient beds is another pressing consideration. The young person's own motivation emerges as crucial at this stage – towards the end of treatment – not only in terms of what is said, and therefore evident verbally, but also through signs of internal shifts in the child that indicate a capacity to re-engage with life outside in a lasting way. Decisions about when to stop are taken with all this in mind and when the decision does not seem straightforward, it can provoke considerable anxiety in the multi-disciplinary team. Clinical material from psychotherapy with a young adolescent boy with anorexia nervosa is used to illustrate some of the dilemmas.     

From cultural to existential diversity: The impossibility of psychotherapy integration within a traditional framework

The authors build upon Castonguay and Goldfried's analysis regarding issues and directions central to advancing psychotherapy integration. They elaborate on two issues addressed only minimally in Castonguay and Goldfried's article. The first involves moving beyond traditional psychotherapy territory to include cultural, self-in-relationship, and interdisciplinary domains. The second concerns using more holistic and synergistic processes to coconstruct integrative theories and approaches. Finally, the authors offer some insights into what they believe should be the goals of the integrative movement and into additional issues they think should be addressed to attain these goals. Psychotherapy has become so complex and changing that we need a new view—one that recognizes the impossibility of any final or superior integrative theory and the need for constant change and evolution in theory and practice.     

The psychotherapy of parenthood: towards a formulation and valuation of concurrent work with parents

This paper explores the process and value of concurrent work with parents when their child is being treated in individual psychotherapy. The position taken is that psychoanalytic understanding generally and the specific formulations presented in this paper have a broader applicability in other aspects and approaches in child and adolescent mental health practice. The central issues are the interweaving of knowledge of family processes, child development and psychopathology, and the uses that can be made of an understanding of transference and countertransference. A particular formulation is presented in relation to aspects of the work that constitute ‘child guidance’ and those that may be considered as ‘psychotherapeutic’ in relation to parental psychopathology. We have coined the term ‘the psychotherapy of parenthood’ to give this work the status it deserves and to define a boundary within which to explore the areas and levels of this complex work. Some practice and training implications are considered.     

The day the earth stood still: The presence of trauma in time experience

The experience of time is commonly perceived as developing within the context of the early relationship between mother and infant. The beginning of life occurs in an adapted environment, aimed to protect the child from internal and external disruptions. Through healthy development, the mind acquires a feeling of continuity that gradually becomes a cohesive sense of personal identity. However, in cases of traumatic interruptions to the primary environment, the defensive shield of the self is penetrated and the individual becomes prematurely aware and adapted to the external reality. This forced acknowledgement of time and reality could be manifested in various types of time disturbances, such as disorientation about time or difficulties in following a schedule. In therapeutic relationships, this drama would be enacted in a struggle against the psychoanalytic setting, which disrupts the continuity of being with the therapist. Importantly, these patients express a deep conscious or unconscious fantasy to live in a timeless world, in which they would not be forced to adapt themselves to others’ expectations or needs. Clinical examples are used to illustrate how traumatic history is evident in the patient’s time experience and in the psychoanalytic dialogue.     

Looking back versus looking ahead: framing of time and work at different stages of a project

Progress on a well‐defined project can be described along a task dimension in terms of amount done, or as amount of work still to be completed. Time‐limited projects can also be described on a temporal dimension in terms of time spent versus time left. Five experiments are reported showing that such frames have predictable implications for speakers as well as for listeners: Statements by a team leader about time spent and work left are perceived as suggestions to “hurry up,” whereas complementary statements about work done and time left indicate that the team can take it more easy. The first set of statements further implies that the team is behind schedule, whereas the last two statements suggest that the team is ahead of the plan. In line with this, speakers preferred work done and time left statements when they were ahead of schedule, but not when they were behind. “Hurry up” and “behind schedule” interpretations were also shown to be dependent upon stage, being more prominent in the final stages than during the initial stages of a project. Copyright © 2005 John Wiley & Sons, Ltd.     

The Effectiveness of Cognitive Behavioral Therapy for Generalized Anxiety Disorder in a Frontline Service Setting

The goal of the current study was to test the generalizability of cognitive behavioral therapy (CBT) for generalized anxiety disorder (GAD) in a frontline service setting. Twenty‐nine patients who presented to treatment clinics with problematic worry were provided CBT for GAD. Among the intent‐to‐treat sample, there were no significant changes in worry or depression from pre‐ to posttreatment. Treatment completers showed significant pre‐ to posttreatment reductions on measures of worry and depression. The magnitude of change was smaller than has been reported in randomized control trials (RCTs). Although the frontline service setting differed from RCT settings in multiple ways, treatment completers nonetheless achieved moderate to large decreases in self‐reported worry and depression.     

The impact of the socio-economic crisis on intrapsychic and intersubjective processes within the therapeutic relationship: Implications for the ethical practice of counselling psychology and psychotherapy

Using attachment and mentalisation theories as a framework, the present paper aims to explore the impact of the current socio-economic crisis on the micro-processes and interpersonal dynamics that emerge between client and therapist as well as the ethical dilemmas that surface within the context of the therapeutic relationship. The first part of the paper focuses on the intrapsychic level and the subjective appraisal and experience of the crisis, as this may differ from individual to individual as well as the unique meaning-making processes that take place for clients and therapists alike. It is argued that the socio-economic crisis itself cannot be seen as an entity that is entirely independent and external to the individual but as a phenomenon that interacts in unique ways with the individual’s inner current and past experience. The second part focuses on the exploration of intersubjective processes that emerge between client and therapist, in particular the transference-countertransference dynamic, as this develops within conditions of increased arousal and anxiety. The role and responsibility of counselling psychologists in preserving reflexivity, empathy and a mentalising stance (through supervision and personal therapy) are highlighted in order to safeguard the ethical and competent practice of counselling psychology.     

Generosity: a psychological and interpersonal motivational factor of therapeutic relevance

This paper examines the role of generosity in analysis. Generosity represents a complex constellation of cognitions and affects that is antithetical to those states of super-ego harshness that characterize many forms of human psychopathology. In development, generosity is evoked by idealization, and a dynamic axis of idealization-generosity promotes relational proximity between the child and its caretakers, and eventually fosters separation and individuation. Generosity is highly sensitive to adverse conditions, and requires environmental conditions that are conducive to psychosomatic well-being. The imaginal basis of generosity is rooted in the myth of the 'hero and the return', which is the mythic foundation of the analyst's role as psychopomp. It is argued that the generosity of the analyst is a cardinal therapeutic factor in treatment.     

Client perspectives: The therapeutic challenge of domestic violence counselling – a pilot study

Aims: This qualitative pilot study explored the perceptions of four female domestic violence clients regarding counselling they had concluded in order to identify a preliminary client‐preferred domestic violence counselling approach. Method: Semi‐structured interviews asking about significant events during counselling were held. An adapted grounded theory and narrative methodology was used. Results from the analysis were reviewed with two of the participants. Participants were offered additional counselling support if required after the research interview. Results/Findings: Domestic violence clients found starting counselling particularly difficult after years of keeping the abuse to themselves. Participants actively withheld and managed information for several sessions and needed to know they had time to explore their experiences. The counsellor being consistent and non‐judgemental, and understanding domestic violence and its effects was helpful. Having a clear ending was appreciated by the participants. Discussion: The initial development of the therapeutic relationship benefited from active discussion of how domestic violence could affect behaviour and emotions. Good early therapeutic relationships showed elements of the three main psychological schools. Participants benefited from a pro‐active discussion of endings. A key limitation of this research is the small sample size. Implications for practice: The research suggests that counsellors would benefit from knowledge and skills from different psychological schools and specific training in domestic violence. Allowing flexibility on the number of sessions available to clients may be helpful. Conclusions: Further work is required to explore these preliminary findings. However, early indications suggest that domestic abuse clients may benefit from non‐time‐limited specialist counselling services.