Mirror mirror on the ward: who is the unfairest of them all? Reflections on reflective practice groups in acute psychiatric settings

Consultant psychiatrists in medical psychotherapy, adult psychotherapists, child and adolescent psychotherapists and clinical psychologists increasingly complement their direct therapeutic activity with applications of their psychotherapeutic thinking in acute mental health work through facilitating reflective practice groups for staff working in mental health teams. The authors offer their reflections on facilitating National Health Service reflective practice groups using the metaphor of a mirrored dialogue between patient and professional, and professional and institution as a basis for informing the development of reflective practice for colleagues. Their reflections are based on working on three acute in-patient wards, in a crisis resolution team and in community mental health teams. They describe the practicalities of setting up and facilitating reflective practice groups, and offer insights into some of the issues that arise in reflective practice groups. They conclude that these groups are mutually beneficial in forging links between psychotherapy professionals and professionals working in other disciplines and areas of mental health. Facilitating these groups often requires a challenging adaptation of technique, which will not suit all psychotherapists, as well as a wider understanding of organisational dynamics and the interplay between clinicians and management.     

Integrative Therapie von narzisstisch gestörten Patienten

The psychotherapy of patients with a narcissistic personality disorder continues to be a psychotherapeutic challenge. There is still no psychotherapeutic program for the treatment of these patients which integrates different psychotherapeutic methods and strategies. Therefore the therapy of narcissistic patients remains difficult and only few psychotherapists voluntarily meet the challenge of treating such patients. In this article an integrative psychotherapeutic concept for the treatment of narcissistic patients using psychotherapeutic methods of different psychotherapeutic schools is presented. This integrative concept includes basic strategies such as working with the therapeutic alliance, schema work and activation of resources. On the other hand specific modules for different core symptoms of these patients are proposed. With this article the authors hope to contribute to a new conceptualization of the psychotherapy of narcissistic patients.     

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.     

Making a case for case studies in psychotherapy training: A small step towards establishing an empirical basis for psychotherapy training

The evidence debate in psychotherapy pays little attention to developing an evidence base for training practices. Understanding effective training requires an examination of what makes training work. This article examines the role of case studies in psychotherapy training. This has not been articulated explicitly or researched systematically in spite of its cardinal importance. An analysis of the role of case studies in psychotherapy training is presented. Reading, watching, or hearing about cases can offer novice psychotherapists access to a closed world; access to psychological theory in action; access to whole courses of therapy; access to different approaches; access to significant moments; access to the therapeutic relationship; access to a wide range of client types; access to working in different contexts; and the opportunity of identifying with therapists and clients. Writing or presenting cases offer students the opportunity of: learning to integrate information into a relevant whole; being in the ‘hot seat’; learning to give appropriate feedback; assessing the validity of interpretations, inferences, and interventions; adapting methods to suit the client; and learning to collaborate with other professionals. The paper presents directions for future research into psychotherapy training, specifically proposing an international survey of training practices at psychotherapy training institutions.     

Gegenübertragung im stationären Therapie-Setting

Background

Countertransference is seen as an instrument of research into a patient’s unconscious and is therapeutically useful in furthering psychodynamic work. For inpatient psychodynamic psychotherapy, where patients are treated by a team of psychotherapists, countertransference is much more complex and makes consideration and integration of different countertransference feelings necessary. Using the first German translation of the countertransference questionnaire (CTQ, Zittel Conclin and Westen, the countertransference questionnaire, 2005) an attempt was made to identify differences in countertransference phenomena in a team of psychotherapists and to show the impact countertransference has on therapy outcome.

Materials and methods

A total of t multiprofessional teams of psychotherapists (15 physicians, 5 psychologists and 9 body and art therapy psychotherapists) took part in the study and completed the CTQ for 137 patients (100 female, 37 male) at the beginning and at the end of inpatient psychotherapy. In addition, the patients completed two questionnaires, the Symptom Check List Revised 90-R (SCL-90) for the severity of symptoms and the Assessment of DSM-IV Personality Disorders Questionnaire (ADP-IV) for personality disorders.

Results

Body and art therapy psychotherapists expressed more positive, protective and involved countertransference feelings whereas psychotherapists for single and group therapy expressed more aggressive and hopeless feelings. Countertransference has an impact on therapy outcome and feelings of a lack of interest, aggression and resignation at the beginning of therapy can point to a poor outcome. Patients with personality disorders activate more negative countertransference reactions than patients without personality disorders but at the same time they may also evoke parent-like feelings of protection.

Conclusions

Using the CTQ it is possible to differentiate countertransference phenomena in a team of psychotherapists treating inpatients with psychodynamic psychotherapy. The timely perception and integration of countertransference feelings has a positive influence on the therapeutic process and therapy outcome.     

Psychoonkologische Therapie und Psychoanalyse: ein Widerspruch?

Psycho-oncological psychotherapy and therapeutic work with severely somatically ill patients seems to be an area of limited interest in psychoanalysis. For example, case reports of psychoanalytic treatment with terminally ill patients are rare. This stands in contradiction to the importance of the fear of dying and death (wish) in psychoanalytic theory construction (e.g. narcissism theory). In addition to the obvious differences between psycho-oncological therapy and psychoanalysis, such as limited time perspective, the need for a flexible setting and dealing with the depth of regression, there are also important similarities and in particular the therapeutic work on early unconscious defence processes and coping with the fear of death. The theoretical and clinical work of the French psychoanalyst Michel de M’Uzan on experiences in psychoanalytic treatment of dying patients are an important example but are not well known in the German psychoanalytic community. The way psychotherapists deal with their own separation anxiety and fear of death is still a major issue and a barely appropriately reflected phenomenon, which possible represents a mutual confrontation (or an impossibility?) of psychotherapeutic work with dying patients.     

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.     

People in groups: Dynamic and therapeutic aspects

The author differentiates between a sociological-interactional (horizontal) axis and a psychological-motivational (vertical) axis in the group, and discusses the socio- and psychodynamics both of and in the group from each of these points of view. In group therapy, five phases are described: 1) exploratory contact; 2) regression; 3) catharsis; 4) insight; and 5) social learning. Group psychotherapy with large diagnostically heterogeneous groups in a hospital setting, small diagnostically homogeneous groups, and group discussions with patients' relatives are all described. In addition, attention is paid to experiential psychodynamic group process groups (analytic self-experience groups), which provide young psychotherapists with the opportunity to gain insight into both groups and the psychodynamics stimulated within this framework. The training of group therapists should include, after academic studies, clinical experience, individual psychotherapeutic training, an experiential group, cotherapy, group therapeutic work under expert supervision, and theoretical training.     

Exploring the bio-psycho-social

The United Kingdom Council for Psychotherapy (UKCP) was formed to provide a professional body for all psychotherapists in the UK. It maintains a register of trained practitioners who abide by the ethical standards ratified by UKCP, which includes psychotherapists working in all the modalities recognized by UKCP irrespective of their primary professional training. In the absence of statutory registration, there is no fully representative list of UK psychotherapists, but the UKCP register is probably the nearest thing to it. The UKCP board recognized that a survey of registrants would provide a snapshot of the state of UK psychotherapy, which would be valuable in understanding the contribution of psychotherapists to health services in the UK.

A questionnaire was designed, and sent out to all 4005 practitioners registered by UKCP in December 1997. One thousand three hundred and thirty-one questionnaires were returned, a response rate of 34 per cent. The respondents were representative of all registered psychotherapists in 1998 in those characteristics that are published in the paper register, or that can be inferred from it. The respondents were aged 51 years on average, predominantly white (97 per cent described themselves this way) women (69 per cent) practising in London and the South East of England (55 per cent). All the respondents described themselves as being influenced by psychotherapeutic approaches rooted in psycho-analysis. Ninety-five per cent of respondents had another profession previous to psychotherapy. This was most commonly teaching (27 per cent), social work (22 per cent) or counselling (21 per cent). Only 11 per cent of respondents were psychologists.

The contribution of UKCP registrants to the National Health Service has never previously been estimated. A breakdown of the diaries provided by respondents in this survey suggests that UKCP registrants may contribute as many as 44,760 hours of psychotherapy per week to the British National Health Service and other health sectors. Assuming that a whole-time-equivalent psychotherapist works 37 hours per week, this means that UKCP registrants may provide the equivalent work to health service organizations, both public and private, of more than 1,311 full-time psychotherapists.     

Politics in psychotherapy: Therapists' responses to political material

This paper reviews the psychotherapeutic literature that addresses the ways in which political material is engaged with by psychotherapists. The paper explores this in both the traditional and contemporary psychotherapeutic approaches. The paper concludes with a recognition of some of the challenges psychotherapy faces in developing politically sensitive approaches which draw upon the lessons learned across therapeutic theory.     

Ambulante Psychotherapie in Deutschland aus Sicht der Patienten

This study analyzed the provision of outpatient psychotherapy services in Germany in standard practice settings. A total of 1,212 subjects who received or were still receiving outpatient psychotherapy during the past 6 years provided information about their experiences via a telephone survey. Outpatient psychotherapy was sought for many different conditions and was rated as highly effective. The improvement rates for all complaints were higher than 50%, except for obesity (37%) and sexual dysfunctions (44%). Patient ratings of worsening were less than 8% throughout. Treatment had very positive results not only for target symptoms but also for other aspects of patients?? lives. Almost 90% of those questioned stated that they were satisfied with their therapist. High agreement ratings were reported specifically with respect to positive therapeutic relationship, stable working alliance, experience of autonomy during therapy and therapists?? competency and ethical conduct. Patients gave their psychotherapists excellent evaluations and were highly satisfied with the changes achieved through treatment.     

Sollen Psychoanalytiker Psychotherapeuten ausbilden?

With respect to the radical changes in psychotherapeutic education as a consequence of the Law for Psychotherapy that has been put into force, the author elaborates on political, medical and strategic aspects. It is of special interest whether psychoanalysts having had the “monopoly” of training in depth psychological therapy should further take responsibility for the training in and the development of this method. Meanwhile, other therapeutic schools are claiming depth psychological psychotherapy for themselves and they deny the essential role of psychoanalysis as a foundation of it. In addition, the psychoanalytic institutes themselves do not agree on this issue. A further aspect of the question is that of marketing strategies: in order to survive, it is for psychoanalytic institutes at a time of lessening interest in standard psychoanalytic training important to offer training in depth psychological therapy with its comparatively less expensive and less extensive curriculum. But the essential question remains: should psychoanalysts train psychotherapists and take responsibility for an independent depth psychological therapy, or not? The author calls for a separate profound education in depth psychology taught by psychoanalysts in order to maintain a positive atmosphere for psychoanalysis e.g. in clinical institutions. He agrees with the IPV that this would help to solve “the crisis of the psycho analysis”. Finally, some of the most important, unsolved questions referring to a separate and profound education in depth psychology are presented and possible solutions are offered. It is of crucial importance to take up again the discussion within the psychoanalytical associations and to adjust their medical as well as political attitude to the new ways depth psychology is taught at psychoanalytical institutes.     

Personal Therapy in Psychotherapeutic Training: Current Research and Future Directions

Recent research literature in the field of personal therapy for psychotherapists shows that therapists claim overwhelmingly positive outcomes with few negative effects (Orlinsky et al., The Psychotherapist’s own psychotherapy: Patient and clinician perspectives. Oxford University Press, Oxford, 2005). However, there has been little interest to date in the extent to which the personal characteristics of therapists might have a bearing on the way in which personal therapy is experienced in psychotherapeutic training. This paper reviews some of the current research in the field and then discusses a subset of results from a small-scale qualitatively-driven study (Rizq and Target, Counselling Psychology Quarterly 23(4):1–27, 2010b) suggesting that early attachment experience may be a relevant factor in understanding how a mandatory training therapy is perceived and experienced within psychotherapeutic training. Implications for psychotherapeutic education are briefly discussed and some directions for future research proposed.     

Therapeutischer Stil und psychotherapeutische Behandlung älterer Patienten

Although the clinical field of psychotherapy for elderly patients is gradually developing, there is still a considerable gap in research on the topic. This mainly concerns questions about the characteristics of psychotherapy for elderly people. Based on clinical experience the therapeutic relationship and therapeutic style are of particular importance. This article presents a survey of psychotherapists who were asked with a questionnaire on their therapeutic style in the treatment of both elderly and younger patients. Data analysis showed differences between the two groups of patients concerning therapeutic technique and the assumed impact factors. In addition, differences between behavioral therapists and psychodynamic psychotherapists are important. The findings are discussed in the context of necessary modifications in the treatment of elderly people and training requirements.     

The development of therapeutic attitudes during and after psychotherapy training

The aim of this study was to explore changes in psychotherapeutic attitudes of students during training in psychodynamic psychotherapy and the first few years after it. Forty-six students were asked to answer a therapeutic identity questionnaire at three times during training and at one time after it. Twenty-one students completed the questionnaire on all four occasions. The questionnaire assessed attitudes on nine scales relating to beliefs about curative elements in psychotherapy, therapeutic style, and basic assumptions about psychotherapy and human nature. At the beginning of training, students had a clear psychoanalytical orientation, similar to that of their supervisors. From the last year of training, after supervision had ended, and continuing during the post-training period, students distanced themselves from the psychoanalytical orientation and their supervisors toward a more eclectic position. This development may reflect the formation of an autonomous therapeutic identity.     

Simulationspatienten in der Psychotherapieausbildung

Background

The development of therapeutic skills is an essential therapist-related variable that deserves special attention in the context of the currently increasingly discussed topic of therapeutic failures and discontinuation of therapy.

Aim

The study investigated whether the use of simulated patients (SP) in the training of psychotherapists can lead to an increase in therapeutic skills.

Material and methods

The use of SP (16 teaching units) was tested in a pre-post comparison with 29 training participants for child and adolescent therapy and analyzed from three perspectives: from the perspective of the SP, the training of participants and rater.

Results

The work with SP in psychotherapy training leads to a significant increase in therapeutic skills; however, it requires further research to see if this teaching method is more effective than other approaches to teaching, whether it contributes to long-term changes in therapeutic skills and to what extent the results can be transferred to other therapeutic contexts (except exploration).     

Onkologisch Kranke als Patienten der psychotherapeutischen Praxis

Background

The high prevalence of cancer and the considerable psychological comorbidity is a challenge for psychotherapists. There are, however, relatively few patients in outpatient psychotherapy. Aim of the study was to survey outpatient psychotherapists concerning this issue and their attitudes towards the treatment of cancer patients.

Methods

All outpatient psychotherapists of an East-German city were surveyed using semi-structured interviews.

Methods

There are various reasons for the relatively rare visits of cancer patients in psychotherapeutic practices: For instance the subjective lack of specific competence, the fear of many psychotherapists to treat physically ill people, insufficient fitting of the relatively inflexible organization structure of psychotherapeutic settings with the vicissitudes of life among physically ill people, e.g. long waiting periods until the begin of treatment, furthermore the psychotherapeutic training focuses on psychosomatic and not so much on somatopsychic perspectives. A further problem is the widespread attitude about psychic causation of cancer, which is contradictory to scientific evidence.

Conclusions

Psychotherapists who want to treat cancer patients need specific and in-depth training in psychooncology.     

Professional values and their development among trainees in psychoanalytic psychotherapy1

Forty-six psychotherapy students in three groups at one training institute for psychoanalytic psychotherapy in Sweden were asked to fill out a questionnaire about important influences on their professional development during their three-year training and afterwards. The questionnaire was distributed on three occasions during the training program and on one later occasion. Twenty-one students responded to the questionnaire on all four occasions. Working with patients in therapy, getting supervision, and participating in personal psychotherapy were viewed as the three most important influences on the students. The importance attributed to specialist literature and technical skills seemed to increase over time during the training, while the influences of experiences in personal life and personal qualities decreased. These changes in reported views were reversed in the initial years after graduation. Concerning assets, the students valued the ability to be containing and emphatic as the most important, but in their first years as licensed psychotherapists assigned more importance to the ability to create contact. The training program led to a change over time in a higher rating for the importance of technical and methodological attributes and less emphasis on personal characteristics and experiences. Most of the changes reported during training tended to be reversed afterwards.     

Language as power in the therapy room: A study of bilingual (Arabic–English) therapists' experiences

The topic of language as power (LaP) in individual therapeutic encounters has thus far been overlooked, and as bilingual therapists have the ability to use more than one language in the therapy room, their experience of LaP is a compelling research area that this paper attempts to explore. This qualitative, inductive, phenomenological study used interviews and interpretative phenomenological analysis to explore five bilingual Arabic–English-speaking therapists' experiences of LaP in the therapeutic encounter. The study identifies two overarching themes: (a) the emergence of identity and power from language and (b) comparisons of power in the English and Arabic languages. Within these themes, the study finds that therapists experience LaP through multiple avenues: self-disclosure, intersectionality, being transported to different identities and expressions of power and power of expression in Arabic–English. These multiple avenues illustrate the complexity of LaP in the therapeutic encounter. The study sheds light on an underexplored area in psychotherapy, illuminating an important area for psychotherapists and training institutions to consider when working with clients.