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.     

Schwere Anorexia nervosa

Background

Psychosomatic support during acute medical treatment of patients with anorexia nervosa is a special need but up to now a rare constellation. These patients can barely accept necessary somatic procedures even if they suffer from severe consequences of the eating disorder. The ambivalence of patients towards treatment is explained by the loss of the right perception of their bodies and the strong obsession with further weight loss.

Methods

This article reports on eight consecutively treated patients on a medical ward who received a liaison psychosomatic, psychotherapeutic visit twice a week. The aim was to maintain better therapy adherence, to support oral food intake and understanding of the disorder as well as to motivate patients for further psychosomatic treatment.

Results

By means of a respectful cooperation between the departments of internal medicine and psychosomatics it was possible to gain psychotherapeutic access to the patients in this highly complicated situation.

Consequence

The psychodynamic aspects of this collaboration are discussed with a focus on the triangulation of the therapeutic process.     

Eine Therapiestunde mit einem Mörder

Although psychodynamic concepts may be helpful in identifying the complex interpersonal and manipulative processes that occur between inmates and therapists and to transform them into the therapeutic process they are hardly ever applied in a correctional setting. The author provides an insight into the psychotherapeutic work conducted in prison. The first part of the paper outlines the special conditions in which psychodynamic psychotherapy occurs in a social therapeutic intervention institution within the German prison service. Characteristic transference and countertransference constellations are described. Based on a verbatim report an account is provided of a therapy session with a serious violent offender. In his reflections on the session the author focuses on the effects on the transference process of, in the offender’s eyes, being both therapist and assessor at the same time.     

Tanztherapie

Dance therapy is presented as a processorientated psychotherapeutic method. Its historical roots in the German Expressive Dance and in the Human Potential Movement in the USA are discussed together with current trends in Germany. Phenomena as rhythm, the experience of space, vitality contours, nonverbal attunement and movement analysis are discussed theoretically and backed up by short examples of dance therapeutic sessions. The integration of psychoanalysis and dance therapy is illustrated by the approach of Elaine V. Siegel, speaking about physical transference and counter transference. The therapeutic work with body image and the idea of creative movement and playfulness for the purpose of a new orientation of Stern’s RIG`s (representations of interactions that have been generalized) are fit in a modern and psychodynamic oriented concept of dance therapy. Questions concerning indication and current research are shortly summarized. Dance therapy, as the youngest creative therapeutic method beside music therapy and art therapy, is characterized by its openness for interactive scopes, the integration of behavior observation (through movement analysis) and psychodynamic reconstructions.     

Zukunft der Psychotherapie in der Psychiatrie

The conceptual development of the German mental health system can only be understood against the background of the specific historical development process; therefore, the emigration of psychodynamic psychotherapists during the Third Reich as well as the complicated reintegration of psychotherapy into psychiatry during the postwar period are of particular relevance. The current discussion concerning the relationship of psychiatry and psychotherapy is characterized by the development of new techniques and methods and the concept of modular psychiatry, whereas the traditional complex psychotherapeutic procedures are becoming less important. In the future, the development of clinical and scientific research should focus on psychotherapy in old age as well as adolescence psychotherapy, the combination of psychopharmacological and psychotherapeutic treatment and issues concerning chronic courses as well as resistance to therapy.     

Die verbale Aktivit?t in therapeutischen Dialogen

The discourse in psychotherapeutic treatment is less specific than usually expected so the question arises whether different therapy methods are different in the style of communication. In this study the verbal activity and other characteristics of the discourse of therapist and patient for sessions from two psychoanalytic, two psychodynamic and two cognitive behavior therapies were compared. Psychoanalytic therapists were found to talk the least and behavior therapists the most. Patients talk nearly the same amount in all therapies. As therapists of psychoanalytic treatment talk less than behavior therapists the percentage of patient talking is highest in psychoanalytic therapy. Further formal characteristics: statements are the most frequent form of intervention in behavior therapy (51?%), followed by psychodynamic (36?%) and psychoanalytic therapy (27?%). The most frequent form of intervention in psychodynamic and psychoanalytic therapy is listening, whereas it is only a small part of communication in behavior therapy. Questions are asked most often in behavior therapy. Hence there are significant differences which correspond to the theory of treatment, between the three methods in discourse behavior on a single case level.     

Nature as therapist: Integrating permaculture with mindfulness- and acceptance-based therapy in the Danish Healing Forest Garden Nacadia

Nature-based therapy can be considered an umbrella term for a diverse range of psychotherapeutic and allied practices which integrate experiences and activities in nature as therapeutic means. The objective of this article is to describe the theoretical framework for nature-based therapy in a university-founded healing forest garden near Copenhagen, Denmark. The garden will offer a 10-week treatment for people who are on sick leave with stress-related illness. This article focuses on clarifying the integration between the psychotherapeutic and gardening aspects of the nature-based therapy. The psychotherapeutic aspects are based on mindfulness and an acceptance therapy, while the gardening aspects are highly inspired by permacultural principles and methods.     

The Effectiveness of Brief Versus Intermediate Duration Psychodynamic Psychotherapy in the Treatment of Adjustment Disorder

Treatment studies and particularly psychotherapeutic treatment studies of patients suffering from an adjustment disorder are very scarce, leading to insufficient evidence regarding the efficacy of treatment in this population. Whereas timely psychotherapy is known to be of benefit in the treatment of adjustment disorders, the ideal duration of psychotherapeutic interventions is not known. This study examined whether a brief 12-session focused psychodynamic psychotherapy may be as efficient as a longer intermediate-term (1?year) psychodynamic psychotherapy in treating patients suffering from an adjustment disorder. Subjects (n?=?66) were randomly assigned to either brief or intermediate psychotherapy. They were assessed by self-report measures and clinician’s evaluation at baseline, end of therapy, and 9?months after therapy was terminated. The results showed a good overall improvement in the whole group. Furthermore, brief psychotherapy was found to be as good as intermediate psychotherapy both at the end of treatment and at follow-up. Although our study was not designed to confirm the efficacy of dynamic psychotherapy in the treatment of adjustment disorders, our results suggest that brief interventions may be good enough in adjustment disorder, thus allowing treatment of a greater number of patients without compromising for the quality and suitability of treatment.     

Psychodynamische Kurzzeittherapie mit erlebnisaktivierenden Interventionen

This short-term therapy model with experiential interventions is based on the basic assumptions of psychodynamic psychotherapy. The focus of treatment is the current psychosocial situation, in which dysfunctional emotional patterns are elicited by specific triggers. These emotional patterns are evidence of anconscious intrapsychic conflict, which has biographically relevant precursors. This conflict and the associated dysfunctional relationships are explored in a supportive therapeutic relationship, formulated in cooperation with the patient and then made accessible in an experience-activating process in the present. The effect is, in addition to the reduction of clinical symptoms, the improvement in managing relationships and improved social competence. The transference is noticed, but it is only addressed if it has a lasting compromising effect on the therapeutic relationship. This therapy model is especially suitable for psychotherapy with time limits of 25–40 hours.     

Individual Therapy via the Phenomenon of Hope for Treating Chronic and Complex PTSD

Evidence-based treatment (EBT) supports different types of cognitive-behavioral therapy (CBT) for treating post-traumatic stress disorder (PTSD). Yet, a growing body of evidence shows a high therapy dropout rate and non-response rate among PTSD patients, especially patients with complex PTSD. A different, short-term therapeutic approach is therefore needed which combines CBT and psychodynamic therapy (PDT) because it is better for patients with chronic and/or complex PTSD to work with clarified stages and an end of treatment in mind. The patient's mental structure is conceptualized as a continuum, and functional problems are regarded as stemming from cognitive structures and unresolved developmental conflict. The five phases of the phenomenon of hope model proposed in an earlier article—a connection phase; an agency and pathway phase (developing a goal-oriented decision-making pattern and learning to plan toward goal achievement); a reconstruction phase; a phase of processing the conflict characteristic of PTSD by utilizing the natural power of hope; and a summary and separation phase—advance a short-term therapy that combines CBT and PDT techniques. This integrated therapy is based on notes that were kept relating to the case study of a chronic PTSD patient.     

“Bridging the Gap”: A reflexive thematic analysis of the experiences of therapy trainees transitioning from psychodynamic counselling to cognitive behavioural therapy

There is limited empirical research and insight into the experiences of therapy trainees who are being taught more than one psychotherapeutic approach during their training. Further understanding is warranted to ensure that a dual modality approach to training (that is, where therapists are trained in two paradigmatically distinct modalities) is experienced as worthwhile and acceptable to trainees and to better understand any challenges faced when transitioning between approaches. The aim of this study was to investigate trainees' experiences of transitioning from psychodynamic counselling to cognitive behavioural therapy (CBT) on a two-year master's degree that offers a dual modality approach to training. Data were collected from a sample of 8 trainees using an online semistructured questionnaire. These data were analysed using Braun and Clarke's (2020) reflexive thematic analysis. Four main themes were identified: (1) perceived competence; (2) preparedness; (3) professional advantages; and (4) external challenges. The findings suggested considerable individual variation in the ease with which participants navigated the transition between therapeutic modalities. Those who found the transition easier used the structure of CBT to provide a framework and point of difference that allowed them to temporarily suspend their psychodynamic learning in order to embrace a new therapeutic approach. Others experienced the move to CBT as posing a threat to their developing identities as counsellors. Recommendations are made on how to prepare trainees for the transition including exploring the psychological impact of transitions, increasing opportunities for reflective practice and facilitating exploration of what it means to be a therapist trained in two distinct therapeutic modalities.     

Psychopharmacological treatment of unipolar depression within the elderly: A discussion paper

Depressive disorders are known to affect all aspects of a person's functioning and are often associated with significant psychosocial impairment. What is unclear is whether these psychosocial issues are consequences or causes of depression; what is known is that these problems do not disappear when the biological symptoms resolve. Existing data on the treatment course and outcome of depression are not generally considered as representative of the older depressed person. Discussion will take place as to whether later life depression should be conceptualized not as a categorical disorder, but as a geriatric syndrome, with multiple aetiologies requiring a combination of treatment interventions. There is general consensus that when intensive psychotherapy is directed towards appropriate patients, geriatric clientele are as able to deal with the viscitudes of intensive therapy as well as any age group. An examination will be undertaken regarding the utilization of psychotherapeutic interventions, namely psychodynamic, interpersonal and cognitive behavioural. Comparative studies have demonstrated all three to be effective, particularly in the treatment of depression. There is a great need for further understanding and research into the appropriateness and efficacy of an integration of psychotherapeutic and pharmacotherapeutic intervention in the treatment of depression, particularly within the elderly. A tantalizing array of research possibilities emerge. If we accept that unipolar depression is a bio-psychosocial phenomena, then we need to understand more about which psychopharmacological treatment paradigms need to be employed, and that perhaps the way forward inclines towards pragmatic integrationism rather than puritanist intervention.     

Class in psychodynamic theory,research and practice

Class is a generally neglected topic within the psychotherapeutic and counselling worlds, and has not benefitted from the psychoanalytic and psychodynamic thought arising from contemporary critiques concerning gender, sexuality, and race. The article presents an overview of my researches over many years in an attempt to formulate the different ways in which considerations of class may impinge on practices and theories in the therapeutic professions. I use a clinical vignette to identify class related issues that may arise within the consulting room, and relate these to wider aspects of the intersections of class with therapy and counselling.     

Infancy research,infant mental health,and adult psychotherapy: Mutual influences

This article considers the influence of infant research on psychodynamic theory and practice. Infant research highlights the dramatic effects of the early caregiving relationship on development throughout the life span. It also provides important perspectives on psychotherapeutic processes. This article highlights such elements as empathy, mutual recognition and attachment, along with elaborating the intersubjective and transactional systems perspectives. In addition, it stresses the powerful role of nonverbal, implicit communication and meaning‐making, which play a greater role in human relational experience–and therefore in the therapeutic process–than previously understood. In addition to clarifying these general orientations, the article describes specific therapeutic strategies based on the expanded developmental knowledge.     

Übertragung und Gegenübertragung in Verhaltenstherapie und Psychoanalyse

Most psychotherapists and researchers agree that a good relationship essentially contributes to therapeutic change. The psychoanalytic concepts transference and countertransference which describe fundamental aspects of the psychotherapeutic relationship have now become integrated into behavior therapy. These concepts, however, are used differently in psychoanalysis as well as in behavior therapy. This makes the communication between psychotherapists coming from different orientations difficult. Therefore, a research approach which describes the important verbal and nonverbal elements of a helpful therapeutic interaction independently from therapeutic orientation could help to evaluate their effectiveness in different psychotherapeutic methods. In this way a culture of integration into psychotherapy could be encouraged.     

Learning and teaching (briefly)

This paper was given as the Annual Ellen Noonan Counselling Lecture on July 2012 and retains some of the spoken style of the lecture. It uses examples of Ellen Noonan’s work to examine aspects of the process of teaching and learning psychodynamic practice. The difficulties of how to embed theoretical knowledge with its clinical application are discussed and the question of what are the key skills of the self-reflective practitioner is raised with reference to whether, and how, they can be taught or learnt. It is suggested that part of this process consists in helping students, and their teachers, to be more comfortable with not knowing, a concept that is both counter intuitive and counter cultural. From this aspects of contemporary therapeutic practice, with specific reference to psychodynamic short-term therapy, are addressed. The paper looks at the ambivalence felt by many psychodynamic clinicians towards working within a short-term paradigm in current workplace settings and how this might be addressed. The paper discusses the intrinsic qualities of a psychodynamic short-term approach and its relation to contemporary therapeutic modalities. It is suggested that the increasing managerial culture, leading to the ascendance of protocol driven, manualised and structured therapies, represents an attack on the relational and must be challenged.     

Lost in translation,found in translation: A case study of working psychodynamically in an interpreter-assisted setting

Effective use of psychotherapeutic treatment in interpreter-assisted settings is well established; however, there has been little discussion of the use of psychodynamically informed treatments in such settings. The literature suggests that therapy facilitated by interpreters is not conducive to psychodynamic approaches due to the presence of a third person, the perceived lack of intimacy, and the difficulties of working with translated material. However, transference, countertransference and other unconscious communications and responses necessarily occur in every therapeutic setting, including triadic therapy using interpreters. This article describes a short-term (12 session) psychodynamically oriented intervention with a 52-year-old Cantonese-speaking man suffering from depression. A female, Chinese-born interpreter assisted in every session. The integral role of supervision in supporting a containing relationship between the therapist and the patient and the difficult emotional responses experienced by the interpreter is highlighted. The article attempts to trace some of the unconscious communications that occurred during the therapy and demonstrates the feasibility of working psychodynamically in an interpreter-assisted setting.     

From interactions to mental representations: Psychodynamic parent – infant therapy in a case of severe eating and sleep disorders

This paper describes the process of psychodynamic psychotherapy with an infant and his family, during a developmental phase in which the infant's mental organization was in transition from the level of interactions to representations. The treatment of a 23-month-old boy suffering from a severe sleeping and eating disorder was initiated in a parent?–?child psychotherapeutic setting. The sleep disorder was a consequence of separation anxiety. Additionally, phobic avoidance of new oral experiences led to an eating disorder. These symptoms had developed in the context of dysregulation of the triadic family relationships (mother?–?father?–?children), which tended to split into two-plus-one relationships. After one year, the setting was changed to alternating individual and family sessions. Due to his developing symbolic capacities, the boy was able to express his inner concerns and his internalised affect-laden experiences through play and actions. His internal world could now be addressed by interpretations. New psychodynamic theories and research results on early triadic development were taken as the theoretical background for the psychotherapeutic work. We understood the course of the treatment and the development of the transference/countertransference relationships in terms of processes of triadification (at the level of interpersonal relationships) and triangulation (at the level of intrapsychic representations).     

Influence of personal therapy on learning and development of psychotherapeutic skills

The aim of the present study was to investigate psychodynamic psychotherapists’ experience of the influence of personal therapy on professional growth during training with a focus on the acquisition of knowledge and the development of psychotherapeutic skills. Thematic analysis was conducted on interviews with former students (N=10) at two training institutes for psychoanalytic psychotherapy. The resulting theme “professional subjectivity” indicated that personal therapy was experienced as having a positive effect on learning and growth of professional skill by facilitating the development of a theory- and knowledge-based professional subjectivity, a personally founded, professional attitude. Important elements of this development are “shared experience,” “personal influence,” and “knowledge integration.” The emergence of professional subjectivity proved to be an important factor in terms of professional advancement for future psychotherapists. Finding and relating to their own subjectivity was crucial in the process of developing a personally founded, professional attitude in the clinical work.