Deutende Interventionstechniken bei Patienten mit schweren Persönlichkeitsstörungen

The growing influence of ego-psychology, self psychology, object relations theory, and interpersonal concepts on the psychoanalytic psychotherapy of patients with personality disorders is reflected in a preference of relational therapeutic strategies and in a controversial discussion of interpretative techniques. It is shown that interpretative strategies are of invaluable importance in many patients with personality disorders. However, modifications of technique necessary for this group of patients should be considered. Especially, transference interpretation in the here and now can be of great use even in the treatment of patients with severe personality disorders. It is of outstanding relevance for the therapist to understand the interactional message a patients infers from his interpretation and to take into account the patient's reaction to the interpretation.     

Commonsense about Psychoanalysis by Rudolph Wittenberg

Obstacles are described that constrain or block the full implementation of Yalom's model of inpatient group psychotherapy. These obstacles include situational constraints that are imposed by the temporal, spatial, and organizational structures of many treatment settings, and attitudinal constraints that consist of therapist and patient resistances to the implications and demands of the model. Recommendations are provided that have proven useful for overcoming these obstacles. They address such issues as: (1) patient confusion with here-and-now focus, (2) tendencies toward therapist-centered interaction, (3) the apparent irrelevance of interactional groups for many patient presenting problems, (4) insufficient time to accomplish interactional goals, and (5) the inability of patients to engage in group processing.     

Discussion: The Narcissism of Small Differences — and Some Big Ones

A broad range of characterologically difficult patients present for treatment in psychotherapy groups. Despite different clinical presentations, including features of the schizoid, borderline, and narcissistic personality disorders, these patients share a common developmental failing. Specifically, these individuals have failed to attain object constancy and the associated stable internalization of tolerably ambivalent representations of the self, and of the other, in relationship with one another. Splitting mechanisms predominate over integrative ones, as primitive defenses are utilized to deal with the individual's powerful needs and fears related to engagement and intimacy. These maladaptive interpersonal styles are clearly illuminated in group therapy, but often to the exclusion of the latent, intrapsychic derivatives of this behavior, with detrimental effects. This paper examines the group therapy of such patients from the perspective of object relations and self psychology theories, models that provide the essential link between the interpersonal and the intrapsychic worlds.     

Obituaries

This article reviews the growing contribution of self psychology to group psychotherapy. The basic self-psychological concepts as they are applied to group dynamics and the treatment process are explored. Tranference, countertransference, and self-restitutive patterns are illustrated in a clinical vignette that includes a “difficult” patient's impact upon the interactional and group-as-a-whole processes. Several directions for future investigation are described.     

Editorial

Group dynamics are the elements that make group psychotherapy unique. When applied to the inpatient group, they illuminate various aspects of milieu treatment. Because of this linkage, the therapy group can be used to educate trainees about (1) systems dynamics on the psychiatric unit and their administrative implications, (2) the vicissitudes of the patient's treatment alliance with the hospital staff, and (3) the psychodynamics of severe psychopathology. In the group, individual defensive operations stand out with special clarity. Their expression is fueled by the group's dynamics. Here, internal object relations are reenacted and the defense of projective identification becomes vivid. The focus of this paper is not on the teaching of group psychotherapy itself, but rather on the use of this modality for the general training of future professionals.     

A short-term grief and loss therapy group: Group members' experiences

Abstract

This article is an evaluative study of a short-term grief and loss therapy group conducted at a large Midwestern university's counseling center. The group was held for students who had experienced loss through death of a significant person. The author examines brief group psychotherapy, special considerations of the college student's grief experience, an adaptation of the brief group model for grieving students, and data gathered from the members of the therapy group. Students' scores on a grief instrument showed mixed results. Group members made journal entries at four times during the group experience. They reported that the group was a supportive and helpful experience; five of Yalom's (1995) eleven therapeutic factors could be discerned. Recommendations regarding the treatment of grieving students in a group setting are made.     

Dynamic Group Experiences for Teachers and Students in the Classroom

Throughout the development of object relations theory and self psychology, the importance of attachments, availability, absences, limitations, and endings have been factors that have informed theory and practice. This article examines the multiple meanings and impacts of terminations in group psychotherapy at the intrapsychic, interpersonal, and group-as-a-whole levels, from the perspective of contemporary object relations theory and self psychology. Emphasis is placed on the initiation of a mourning process, with the dynamics of guilt, shame, and aggression toward objects who are separate or inaccessible, and the experience of a shortcoming or absence, associated with a loss of self-object oneness, soothing and idealization from the narcissistic sector of the personality. Therapeutic opportunities afforded by terminations and the importance of resolving countertransference reactions are highlighted.     

Advances in Neuropsychoanalysis,Attachment Theory,and Trauma Research: Implications for Self Psychology

In 1971, Heinz Kohut, trained in neurology and then psychoanalysis, published The Analysis of the Self, a detailed exposition of the central role of the self in human existence. This classic volume of both twentieth century psychoanalysis and psychology was more than a collection of various clinical observations—rather it represented an overarching integrated theory of the development, structuralization, psychopathogenesis, and psychotherapy of disorders of the self. Although some of these ideas were elaborations of previous psychoanalytic principles, a large number of his concepts, including an emphasis on self rather than ego, signified an innovative departure from mainstream psychoanalysis and yet a truly creative addition to Freud's theory.     

J.L. Moreno: An Unrecognized Pioneer of Family Therapy

J.L. Moreno's fundamental and pioneering contributions to the development of group therapy, encounter, transactional analysis, and especially psychodrama are well known. However, most family therapists seem unacquainted with the fact that from his earliest writings in 1923 J.L. Moreno developed an interactional view of psychotherapy that in 1973 already resulted in formulations of a true systems orientation and very concrete ideas about marital therapy, family therapy, and network therapy. He probably is the first (1937!) therapist that actually involved a husband's lover in conjoint marital therapy. His general theoretical formulations about the pathology of interpersonal relations as well as his practical suggestions for the therapy of the interpersonal relations seem to be insufficiently known to workers and researchers in the field of family therapy.     

The Patient-Staff Community Meeting: A Tea Party with the Mad Hatter

The author shows how object relations group therapy focuses on primitive defense mechanisms that shape the group-entity image or “basic assumptions group.” Such primitive defense mechanisms as splitting, projective identification, omnipotent denial, projection, and introjection are the mental resources to protect the endangered self and the threatened objects from the fantasized imminent destruction. Object relations group psychotherapy addresses those defenses and the underlying psychotic anxieties, offering members opportunities to search for other ways to respond to their primitive fears. The author introduces two extensive clinical vignettes to illustrate how object relations group methods are different from other group-centered psychoanalytic techniques. He concludes by commenting on future theoretical refinements and on the problems in the professional practice of this modality.     

Group Psychotherapy in the Treatment of Acute Emotional Disorders

The authors have constructed a Dutch version of Yalom's “Questionnaire for Curative Factors.” This Dutch version has been administered to 134 participants of 22 psychotherapy groups in various psychiatric services in the Netherlands. Results concerning validity and reliability of the instrument are presented, as well as concerning the homogeneity of the hypothesized “factors.” Differences between types of groups and categories of group members were tested by means of techniques of analysis of variance (ANOVA). Multiple regression analysis was applied in order to detect variables of differential qualities on one or more factors. Only the factor identification, neglected in literature on curative factors, was highly predictable.     

Feuerbach's theory of object‐relations and its legacy in 20th century post‐Hegelian philosophy

This paper focuses on the way in which Feuerbach's attempt to develop a naturalistic, realist remodeling of Hegel's relational ontology, which culminated in his own version of “sensualism”, led him to emphasize the vulnerability of the subject and the role of affectivity, thus making object‐dependence a constitutive feature of subjectivity. We find in Feuerbach the first lineaments of a philosophical theory of object‐relations, one that anticipates the well‐known psychological theory of the same name, but one that also offers a broader metaphysical basis in which all types of “essential objects” are shown to matter to subjectivity. This Feuerbachian theory of object‐relations, the paper then argues, foreshadows a number of important developments in 20th century post‐Hegelian philosophy. In it can be found an anticipation of Adorno's later theory of mimesis. Equally, this theory already emphasizes the “libidinal” nature of intentionality, in a way that announces Merleau‐Ponty's ontology of the flesh. Finally, the last section of the article proposes a model with which we might reconstruct the way in which object‐relations and self‐relations can be brought together consistently. In this instance, Feuerbach uses concepts that announce Freud's notion of “primary narcissism”. One contemporary philosopher who has proposed a sophisticated model of subjectivity, in which primary narcissism is shown to complement object‐dependence, is Axel Honneth. The last section argues that Feuerbach's full image of subjective identity as reciprocal scaffolding of self‐ and object‐relations reminds strongly of Honneth's core concept of “positive self‐relation”.     

Basic Considerations in the Application of Therapy and Education to Parent Groups

This article presents a couples group therapy treatment approach that uses analytic object relations concepts such as transference/countertransference, projective identification, containment, and the holding environment. Object relations theory is seen as the most useful theory with which to view couple interaction because it is based on a two-person psychology and focuses on the impact of relational systems on the development of the person. This includes the idea that the person grows within the attachment to another person. Group therapy is seen as a more effective treatment approach because the group is a resilient holding environment that provides an avenue in which projective identifications can be understood and contained, power can be redefined, isolation of the couple can be decreased, and the couple's responses can become more versatile. The model described is illustrated with clinical vignettes from an open-ended couples group.     

Parallel Group Treatment of Pre-School Children and Their Mothers

Object relations concepts are applicable in children's group psychoanalytic psychotherapy. The author attempts to explore and delineate areas in which developmental conflicts in object relations, emotional deprivations, traumas, and family pathologies are recapitulated in the group, and how the manifestations of pathologies can be rectified by the process and formation of the group and the role of the therapist as a “new object” in the management of individual and group transferences. Clinical examples are presented.     

On the Future of Group Therapy Theory

The author presents a hypothetical view of group therapy theories as they may evolve over the first decades of the New Milennium. Looking at the problem of prediction from the standpoint of postmodernism and social constructivism, the importance of these perspectives as frameworks of the social sciences is emphasized. The influence of general systems theory, Foulkesian group analysis, object relations theory, self psychology, cognitive-behavioral psychology, and neuropsychiatry are briefly examined with respect to the expected evolution of increasingly sophisticated, detailed, and nuanced theories of group psychology and group psychotherapy.     

The Development,Process, and Evaluation of Group Psychotherapy With Sexually Abused Preschool Girls

The development, process, and evolution of group psychotherapy specifically designed for sexually abused preschool aged females is presented. Utilization of male and female cotherapists, group structure, individual and family dynamics, the role of children's mothers in treatment, and process of treatment are examined. Issues regarding countertransference phenomena, cotherapy relations, in-depth involvement of the children's mothers, and specifics related to structuring of a time-limited group are beyond the initial intent and scope of this paper, and are not discussed here.

The cotherapists conclude that group psychotherapy for children of this age group is both clearly valuable and highly indicated as an adjunct treatment modality. In future group psychotherapy with sexually abused preschool aged children, based upon clinical experience and evaluation, the cotherapists advocate a time-limited approach whereby each session would focus upon specific issues as illustrated in Table 1, and include structured and purposeful involvement of the girls' caretakers.     

The courage to stay in the moment

In 1934, James Strachey wrote that the active ingredient of psychoanalysis was the mutative interpretation. Even at this early date, Strachey observed that a relatively small proportion of the analytic literature was concerned with the mechanisms for change implicit in the analytic model.

In this paper, the author proposes two modifications of Strachey's ideas. One is that it is a moment, an event, and not an interpretation as such that creates change. The author terms this the ‘mutative moment’. The other modification is the proposal of an unconscious internal group matrix as an image of the structure of self. This is a self that is at one and the same time, internal and external, individual and social.

Building upon Freud, the object relations theorists, Kohut and the work of group analysts, the author pinpoints where and how change occurs in both individuals and in groups. The active ingredient of change is the focus on the here-and-now, a perspective common to both therapists and counsellors. As an understanding of the meaning of this focus develops, it becomes apparent that it takes courage to stay in the moment.     

Group psychotherapy of the characterologically difficult patient

A broad range of characterologically difficult patients present for treatment in psychotherapy groups. Despite different clinical presentations, including features of the schizoid, borderline, and narcissistic personality disorders, these patients share a common developmental failing. Specifically, these individuals have failed to attain object constancy and the associated stable internalization of tolerably ambivalent representations of the self, and of the other, in relationship with one another. Splitting mechanisms predominate over integrative ones, as primitive defenses are utilized to deal with the individual's powerful needs and fears related to engagement and intimacy. These maladaptive interpersonal styles are clearly illuminated in group therapy, but often to the exclusion of the latent, intrapsychic derivatives of this behavior, with detrimental effects. This paper examines the group therapy of such patients from the perspective of object relations and self psychology theories, models that provide the essential link between the interpersonal and the intrapsychic worlds.     

Truth and the ‘Politics of Ourselves’

The authors take up Amy Allen's suggestion that while Foucault's work may be able to support a certain type of self‐critique and self‐development, it does not permit the kind of interpersonal relations that are necessary for the development of intersubjective meaning in struggles against imposed identities. The authors contend that for Foucault, relations of ‘truth’ play an important constitutive role in subjectivities, and that understanding the ‘politics of ourselves’ in the context of this truth shows not only an openness to meaningful interpersonal relations, but also that these relations are capable of generating the conceptual and normative resources necessary for resisting socially imposed subjectivities. The authors present such an account of intersubjective relations based on Foucault's discussion of parrhesia, and develop a model of collaborative political action that addresses the criticisms raised.     

Forgiveness,Cognitive Restructuring and Object Transformation

Forgiveness is described as a process that includes (1) re-constructing cognitions about the offender and self and (2) re-imaging the offender and re-experiencing self and violator. Object relations theory can help to show that the violated individual’s conflict is within as the person struggles inwardly with hostile images (object-representations) during the process of forgiveness. Cognitive restructuring points to the crucial importance of choice to help initiate the forgiveness process. Within the context of forgiveness as a therapeutic process, cognitive restructuring and object transformation can promote the client’s psychological health and well-being. It is proposed that forgiveness is a spiritual as well as a psychological process, which includes grace-filled choices and behavior. Patrick F. Cioni's academic background includes a Master’s of Arts in Psychology with a major in Personality from New School University, New York, N.Y. Previously, he obtained a Master of Science in Counseling from the University of Scranton, Scranton, PA. He began private practice of counseling and psychotherapy in September 1983 following work in the psychology department of a maximum security mental hospital as psychotherapist and treatment team coordinator. Present practice includes individual and marital therapy. He developed a treatment program for use with married couples in conjunction with the Prepare/Enrich inventory. The author wishes to thank Cheryl L. Sancafon, M.D., who encouraged his interest in object relations, Jared P. Pingleton, Psy.D., John C. Norcross, Ph.D., other reviewers and, most essentially, the Spirit of God. Correspondence to Patrick F. Cioni, Private Practice of Counseling and Psychotherapy, 138 South Cameron Avenue, Scranton, PA, 18504, USA; e-mail: patrickcioni@netzero.net