Group Psychotherapy With Ego Impaired Children: The Significance of Peer Group Culture in the Evolution of a Holding Environment

In this paper, we will attempt to delineate the process by which peer group culture emerges and develops among groups of ego impaired children. The process of culture building in groups, as will be illustrated in a detailed case presentation, is critical for the child's development of skills for structuring and ordering the internal and external worlds. By definition, ego impaired children lack the ability to organize their internal experience. The challenge of group treatment with these children is to provide a situation in which their maladaptive efforts to organize volatile affects and impulses can be tolerated and structured. If they are provided with an adequate holding environment, the children learn to create cultural structures (i.e., therapeutic group culture), for the representation of salient aspects of their emotional lives creates the basis for internal organization. Their growing capacity to build integrating structures, at first collectively within the group, (Pfeifer and Weinstock-Savoy, 1984), which previously could only be provided by the therapist functioning as an auxiliary ego.     

Predictors and consequences of sudden gains in transdiagnostic cognitive-behavioural therapy for anxiety disorders

Sudden gains—substantial stable symptom improvements between consecutive therapy sessions—are a common phenomenon. As condensed points of change, examination of sudden gains can provide insight into mechanisms of therapeutic change. This study investigated the association between sudden gains and cognitive change, therapeutic alliance, and/or client engagement in transdiagnostic group cognitive-behavioural therapy for anxiety disorders. Of 58 treatment initiators, 21% (n = 12) exhibited a sudden gain. Consistent with previous research, sudden gainers demonstrated significantly greater pre- to post-treatment symptom improvement than non-sudden gainers. Observational coding of therapy sessions found that sudden gains were associated with elevated levels of cognitive change and client engagement in the pre-gain session, and elevated levels of cognitive change and therapeutic alliance in the post-gain session. However, these results varied by use of within- and between-subject control comparisons, highlighting the value using a dual control methodology. In context of previous research, the results on cognitive change replicate previous findings in depressive populations, and clarify mixed findings in anxiety populations. The results on therapeutic alliance replicate previous findings for the first time in an anxiety sample, although the between-subject control comparisons revealed complexity previously undetected. This study was also the first to investigate and thus establish the relation between client engagement and sudden gains.     

Voice of a hidden minority: Identification and countertransference in the cross-cultural working alliance

This paper has expanded the psychoanalytical definition of the working alliance to include the influence of culture. The cross-cultural working alliance is a therapeutic dyad that incorporates a psychotherapist and a patient of dissimilar backgrounds. Each participant enters the alliance with cultural introjects--values, attitudes, and ways of behaving that stem from ethnocultural roots. These introjects influence the intrapsychic world, shape the conscious worldview, and the perception of life experience. The influence of cultural predispositions on the psychopathologies of the patients was prominent in two case examples: a black West Indian male and a Korean-American male. The therapist also brought cultural predispositions to her work. A constructive countertransference phenomenon occurred in the working alliance that had a direct connection to its cross-cultural nature. This phenomenon is called associative identification--the conscious identification of therapist with the ego experience of patient. With the use of the associative identification, the therapist uncovered parallel memories that promoted theoretical understanding and informed therapeutic technique. Just as anthropologists claim that cultures share universal institutional patterns, it is proposed that universal cultural conflicts may also be observed in the cross-cultural working alliance. The analyst and patients in this study had two culture-conflicts in common: the longing to be seen, and the pull for disidentification. It is concluded that associative identification enriched the reparative quality of treatment, and encouraged the integration of isolated, split-off parts of the self.     

Satisfaction with Components of the Therapeutic Model: Perspectives of Consumers and Professionals

We provide information about consumer and provider perceptions using a mixed-model pilot study within the Intensive Mental Health Project (IMHP), a school-based treatment service for children with SED and their families. Caregiver, youth, and provider questionnaires developed for this project elicited quantitative and qualitative information on treatment satisfaction, therapeutic alliance, and active involvement in treatment. Caregivers and children overall had positive perceptions of the services they received through IMHP. Providers reported very good working relationships with most children and families. Consumers also provided constructive comments about how to improve services. Our results add support to the importance of therapeutic alliance and collaboration, which are guiding principles of the IMHP.     

Clinicians’ Attitudes Toward Therapeutic Alliance in E-Therapy

Although therapeutic alliance is a crucial factor in face-to-face therapies, no data exist on clinicians’ attitudes towards alliance in E-therapy. The study explored clinicians’ perceived importance of alliance in E-therapy, clinicians’ confidence in their skills to develop alliance in E-therapy, and whether attitudes towards alliance in E-therapy are associated with intended E-therapy practice. Clinicians (n = 106) responded to an online survey. The majority of clinicians considered alliance to be extremely important in both face-to-face therapy and E-therapy. However, clinicians’ ratings of the importance of alliance in face-to-face therapies were significantly higher than their ratings of the importance of alliance in E-therapy. Clinicians reported less confidence in their skills to develop alliance in E-therapy than in face-to-face therapy. Intended E-therapy practice correlated with confidence in one's ability to develop alliance in E-therapy and with previous E-therapy practice.     

Relational dynamics between psychotherapy clients and clinic administrative staff: A pilot study

Extensive empirical research has established therapeutic alliance as one of the most stable predictors of psychotherapy outcomes. Nearly all the contemporary empirical literature on therapeutic alliance focuses on the therapist-client dyad without attending to the relational experiences many clients in outpatient clinics have with administrative staff. Literatures from the fields of social work, psychiatric nursing and milieu therapy suggest there are more systemic relational and environmental dynamics that impact treatment beyond the therapist-client dyad, although these issues have been considered primarily in inpatient settings. A relational ecology framework has been developed drawing upon relational psychoanalysis, attachment theory and symbolic anthropology to help conceptualise the broader relational dynamics beyond the therapist-client dyad that may impact a more systemic therapeutic alliance in certain outpatient contexts. In an initial cross-sectional pilot study with a sample of clients (N = 107) receiving psychotherapy at a community mental health clinic in the Northeastern United States, the present study found client ratings of both (a) the therapeutic alliance with their therapists and (b) their alliance with administrative staff each significantly positively predicted client ratings of treatment. Thus, ratings of administrative alliance predicted client ratings of treatment over and above the effects of the therapist-client therapeutic alliance. These findings provide preliminary support for further investigation of the relational ecology of outpatient psychotherapy and suggest that client experiences of relational and environmental dynamics with administrative staff may be important contributors to psychotherapy outcomes. Limitations of the present study and implications for future research and practice are discussed.     

Therapeutic alliance and progress in couple therapy: multiple perspectives

Therapeutic alliance research in couple therapy using multiple perspectives and longitudinal data has been sparse. This study used structural equation modelling to explore relationships between changes in alliance and in progress from clients' and therapists' perspective in a fairly large sample of couples (N=195) during the initial stage of therapy at an on‐campus training clinic. Self‐rated alliance was measured after sessions 2 through 4 with the Working Alliance Inventory. There was very little change in alliance over the early sessions of therapy, and changes in alliance did not always account for changes in relationship satisfaction. Husbands' perceptions of satisfaction and alliance seem to play an important role in the dynamics of the therapeutic process. Findings suggest a reciprocal relationship between perceptions of alliance and progress in therapy when combining perceptions of therapists and couple clients. Clinical implications and future research are discussed.     

Ego Development during the Transition from Adolescence to Young Adulthood: A 9-Year Longitudinal Study

Although Loevinger's (1976) ego development theory represents a milestone approach to life-span personality development, little is known about ego development during the transition from adolescence to young adulthood, including the average gain in group means, whether individuals maintain their relative position to each other, and age-related changes in within-cohort variability. These issues are examined using the ongoing Block and Block Longitudinal Study. Across a 9-year interval—from age 14 to age 23—the findings indicate that: (a) the average person gains approximately 1.5 ego development steps, (b) within-cohort variability in ego development increases with age, (c) ego level at ages 14 and 23 is moderately related, (d) large individual differences exist in the timing and extent of ego development, and (e) the magnitude of change is smallest for individuals who have already reached the Self-aware level as adolescents. The findings suggest that the Self-aware level represents a developmental “hurdle” during the transition from adolescence to young adulthood. Possible explanations are explored in terms of pacers for ego development.     

Making the Parents as Partners Principle a Reality: The Role of the Alliance

We explore the dimensions of the Parents as Partners principle, the widely touted, but somewhat elusive construct in the literature on treating children with serious mental illness, whose poorly defined boundaries, lack of empirical grounding, and overemphasis on instrumental dimensions attenuates its usefulness as a guide for practice and research. Four major barriers to the realization of this principle are outlined, all of which may impede actualizing partnership in practice and may also inhibit the early formation of a positive clinician/parent alliance, a neglected, though key dimension of true partnership practice. The alliance, which has a long clinical and research history in psychotherapy and behavioral research, and more recently, in a variety of community-based interventions, is a precursor to active client partnership with helpers and to treatment participation, as well as therapeutic in its own right. After reviewing relevant alliance research, we close with a beginning research agenda to incorporate the alliance as an integral component of future conceptualization and research about the Parents as Partners principle.     

The Association Between Therapeutic Alliance and Treatment Outcomes in a Group Triple P Intervention

A growing literature has examined the association between therapeutic alliance and treatment outcomes in child therapy. Few studies, however, have specifically investigated the role of therapeutic alliance within evidence-based parenting programs for children with externalizing behavioural difficulties. The current study prospectively collected measures of therapeutic alliance for 117 families completing a Triple P parenting program in a community children’s mental health center. Higher levels of mother and father rated therapeutic alliance were associated with greater gains in parenting skills and parental sense of competence. Parental rated therapeutic alliance was also associated with greater improvements in child conduct problems for mothers, but not fathers. However, therapist ratings of therapeutic alliance had limited associations with treatment improvement. The implications of the findings for clinical practice are discussed.     

Converting a Freudian analysis into a Jungian one: obsession,addiction, and an answer from Job

In his analyses of obsessional patients, Sigmund Freud suggested that they suffered from intrusive cognitions and compulsive activities. Early psychoanalysts delineated the phenomenology of obsessionality, but did not differentiate what is currently termed obsessive‐compulsive disorder from obsessional personality. However, it was widely recognized that the success of psychoanalysis with obsessional patients was limited due to rigid characterological defences and transference resistances. The present paper examines the case of a middle‐aged obsessional academic who had been treated for nearly twenty years in a ‘classical' Freudian psychoanalysis prior to entering Jungian analysis. It examines how persistent focus on Oedipal conflicts undesirably reinforced the transference resistance in this obsessional man, and suggests that focusing instead on diminishing the harshness of the super‐ego via the therapeutic alliance, and fostering faith in the salutary aspects of unconscious processing has led to salutary results in this case. The biblical book of Job is adopted as ancient instruction in how to address the scrupulosity and addictive mental structuring of obsessionality in analysis.     

The supervisory alliance: Comparison of measures and implications for a supervision toolkit

Background Clinical supervision lies at the core of the professional development of clinicians providing services within a range of service settings. The supervisory alliance is regarded as the most important construct in effective supervision which underlies the importance of metrics to assess this construct. Aims materials and Method A cross‐sectional self‐report questionnaire design was used to examine clinical supervision constructs. The study used two scales measuring the supervisory alliance (SRQ and SWAI‐T), a scale measuring supervision satisfaction (SSQ) and a scale measuring disclosure (TDS). The questionnaires were administered to 127 clinical psychology trainees who were undertaking a practicum placement. Results Both scales measuring the alliance were positively correlated with satisfaction with supervision and disclosure, with similar sizes of correlation for each alliance scale. There was also a large, positive correlation between the two scales of measuring the alliance. Discussion Both scales were designed for use in supervision and are related to supervision outcome measures in the expected directions. Conclusion The SRQ has some distinct advantages over the SWAI‐T that lend the SRQ to be potentially more useful in clinical and research settings.     

Critique of the "therapeutic ego split"

The technical relevance of the concept of a therapeutic ego split is rigorously examined. In the author's view, the distinction between a neurotic transference and a non-neurotic working alliance serves the therapist as a defense against anxiety rather than as a clarification of his intricate involvement with the patient.     

Breaking the Solid Ground of Common Sense: Undoing “Structure” with Michael Balint

Balint's great merit was to question what, in the classical perspective, was assumed as a prerequisite for analysis and thus located beyond analysis: the maturity of the ego. A fundamental premise of his work was Ferenczi's distrust for the structural model, which praised the maturity of the ego and its verbal, social, and adaptive abilities. Ferenczi's view of ego maturation as a trauma derivative was strikingly different from the theories of all other psychoanalytic schools and seems to be responsible for Balint's understanding of regression as a sort of inverted process that enables the undoing of the sheltering structures of the mature mind. Balint's understanding of the relation between mature ego and regression diverged not only from the ego psychologists, who emphasized the idea of therapeutic alliance, but also from most of the authors who embraced the object-relational view, like Klein (who considered regression a manifestation of the patient's craving for oral gratification), Fairbairn (who gave up the notion of regression), and Guntrip (who viewed regression as a schizoid phenomenon related to the ego weakness). According to Balint, the clinical appearance of a regression would depend also on the way the regression is recognized, is accepted, and is responded to by the analyst. In this respect, his position was close to Winnicott's reformulation of the therapeutic action. Yet, the work of Balint reflects the persuasion that the progressive fluidification of the solid structure could be enabled only by the analyst's capacity for becoming himself or herself [unsolid].     

Searching for the High-I

This paper questions the nature and existence of the ego and I from a Western and Eastern viewpoint, which has been a question for 2,500 years when the Buddha rejected the Brahman idea of ātman. The answer for an ego depends partly on the state of consciousness; the existence of the Western objectifying ego is undeniable in ordinary consciousness, but not in extraordinary consciousness with no objectifying. The subtle question remains about the existence of an I that is distinct from the ego and that is best represented by most meditative or contemplative states. Here a subjectified, witnessing, consciousness-maintaining I still seems to exist. This may be called the “High-I,” which appears to provide for all states of consciousness a constancy and awareness not provided by the ego. This finding has implications for psychology and religion as well as philosophy.     

Man on a Pendulum by Israel J. Gerber

Group therapy provides the ideal arena for helping individuals cultivate the observing ego—that part of the sensorium that has the power of witnessing oneself in the world. The essence of our method is to employ the group as a temporary observing ego, out of which members may develop their own observing egos. A five-step process is presented to (1) help the members see how they are affecting others when they do not see this themselves, (2) help the members see how they produce this effect, (3) help the members see the self-injurious nature of their behavior, (4) resolve resistances to seeing any of this, and (5) help the members arrive at new modes of behavior.     

The Value of Integration: Psychoanalytic Psychotherapy Meets Ego Psychology in a Psychotherapy Group for Children

ABSTRACT

Psychotherapy integration requires us to look beyond the confines of a particular theoretical or technical approach towards other perspectives. Integrative work with children, in particular, meets the socio-emotional needs of the child while simultaneously modeling behaviors and skills. This paper presents an explicitly integrative approach to child group psychotherapy: Relationships. Individuals. Skills. Engagement (RISE) Group. We begin with an in-depth discussion of the RISE group structure illustrated by clinical examples (the “what”) followed by a review of the theory and treatment modalities that inform the approach (the “why” and “how”). The RISE group is grounded in two theoretical perspectives (psychoanalytic principles and ego psychology) and draws upon clinical techniques from multiple treatment modalities (including cognitive behavior therapy, psychodynamic play therapy and dialectical behavior therapy). Combined, the merger of these perspectives results in a multilevel intervention that forges pathways to mastery and competence within the child. Finally, we discuss the value and limitations of integration as applied to group psychotherapy for children.     

Therapeutic techniques for the treatment of certain infantile personality disorders in ego disturbed children

This paper has discussed certain ego disturbed children of preschool and school age with infantile personality disorders. Although these children do not form a sharp diagnostic category, it is of clinical importance to differentiate them both from the neuroses and from other more serious ego disorders. These predominantly infantile children suffer chronic ego arrest and deviations as well as some degree of internal conflicts. Reality adaptation is characteristically distorted, ego defenses imbalanced, and social relations aberrant. Unlike some other borderline types, however, these children have no significant potential for psychosis. They are not prone to panicky anxiety attacks, or to psychoticlike ego regressions or withdrawal. Ego disturbed children with infantile personality disorders pose certain typical problems of therapeutic technique. They do not possess the ego strength for classical analysis, nor are they suitable candidates for a purely supportive or nurturing treatment. I have argued that the particular psychopathology of these children requires a form of corrective developmental treatment in which the therapist plays a flexible role and uses a combination of techniques corresponding to the child's progressive ego development. Early in treatment primarily supportive and nurturing techniques are used to promote a corrective identification and strengthen the defenses. As treatment proceeds, however, selected interpretations are introduced to modify the internal conflicts that block personality integration and development. Especially important are the mobilization and interpretation of hostile aggression. In the later treatment phases the therapist becomes increasingly more frustrating to the child's infantile wishes, encouraging reality adaptation and social maturation. The various shifts in therapeutic technique create resistances whose interpretation and working through are integral to the treatment process and cure.     

Cognitive errors,coping patterns,and the therapeutic alliance: A pilot study of in‐session process

Aim: This exploratory study examined the association between clients’ assessment of the therapeutic alliance and their cognitive errors (CE) and coping action patterns (CAP). Method: Selected therapy sessions of clients (N = 26) were rated for cognitive errors and coping action patterns using the CERS and CAPRS methods (Drapeau, Perry, & Dunkley, 2008; Perry, Drapeau, & Dunkley, 2005). The therapeutic alliance was assessed using the Working Alliance Inventory (WAI; Horvath & Greenberg, 1989). Results: Following Bonferroni corrections, no significant relationship was found between clients’ CEs and their ratings of the WAI. However, the ‘Negotiation’ CAP was associated with the total alliance score, and with the Task and Goal subscales. Implications: A better understanding of the cognitive processes presented by clients in session can enable clinicians to address these factors early on when the alliance is most critical.