Broaching and exploring the question of combined group and individual therapy

Combined therapy is defined as concurrent dyadic and group therapy with the same therapist. This paper focuses on a neglected aspect of combined therapy: broaching and exploring this question with one's individual patient. The author shows how raising this question: (1) alters the therapeutic field whether or not the patient joins; (2) can sharpen the therapist's understanding of the indications and contraindications for group membership; (3) offers untapped therapeutic approaches and opportunities to classify issues in the individual treatment; and (4) stirs up countertransference issues related to issues of profitability, the transference of the patient in individual treatment, and the transference of the group-as-a-whole. Several case examples are provided.     

Five Issues in Training Edited by Irving R. Weschler and Edgar H. Schein

This case study illustrates how combined therapy (individual, group, and marital) by the same therapist was used to resolve a woman's narcissistic transference. The author's position is that combined therapy creates a psychologically stimulating environment, which uniquely elicits a depth and range of transference feelings, thereby generating multiple therapeutic opportunities to experience and work through transference resistance in the here-and-now. Highlights of the treatment demonstrate how the synergy of three modalities is used to elicit, modulate, and resolve positive and negative aspects of the narcissistic transference. Four guidelines are suggested for treatment of patients in combined therapy.     

7. Guided Group Interaction in a Correctional Setting

Review of the origins of group psychotherapy reveals concerns with social as well as with personal “psychopathology.” Thus, group processes have been mobilized for curative or change purposes for ideological as well as individual therapeutic goals. Psychopolitical as well as personal change are the goals for some groups. The ethical problem stems from a persistent assumption that the group's processes are inherently benign and curative and beneficial to individual participants. A more sophisticated understanding takes into account their essential neutrality and their potential use (or abuse) for purposes of ideological persuasion that may or may not be personally therapeutic. As in other ethically implicated issues in the psychotherapies, the question becomes one of treatment versus exploitation, or therapy for the individual versus recruitment on behalf of a cause.     

Seeing and Being Seen: Courage and the Therapist in Cross-Racial Treatment

ABSTRACT

Correction of the patient's distortion is often the focus of therapeutic treatment. However, the therapist's distortions, based upon pre-existing fears, which themselves are often rooted in greater societal issues and energized by the work with the patient (especially as they relate to issues of racial difference between the therapist and patient), can lead to clinical impasse. Just as an effective treatment relies upon the patient's opening up to correcting distortions, so too the therapist must be able to use transference response and become vulnerable to knowing and moving beyond his own fears and distortions.     

Medicating Patients in Psychoanalytic Therapy: Implications for Introjection,Transference, and Countertransference

If a patient comes for psychotherapy or psychoanalysis, why medicate him with psychotropic drugs? The answers to this question are explored and addressed from several points of view. The central hypothesis of this paper suggests that most of the reasons for medicating patients have to do with therapist's unresolved countertransference issues. Furthermore, medicating a patient may have deleterious effects on his introjected sense of self, and impacts the transference relationship in a significant way. The issues surrounding medication as adjunctive therapy are elucidated and clarified in terms of rationale, efficacy, and the impact on the psychotherapeutic relationship. Psychoanalytic solutions are offered and discussed.     

A current look at transference in combined analytic therapy

This article examines transference from the vantage point of combined analytic therapy, a model that starts the patient in individual analytic treatment, then introduces him/her to group with the same therapist. Definitions of transference in the psychoanalytic literature are noted, as is the designation of transference interpretation as the distinguishing characteristic of psychoanalytic treatment. Working with transference is examined clinically, with attention to archaic transferences as well as more developed responses. In comparison with individual treatment, combined therapy offers an enlarged arena for the transference to emerge, because of the reexperiencing of the family gestalt in the group, and the more immediate stimulation in the group of envy and competition. Communications in the individual session enlighten the therapist further about what has gone on in the group.     

Creative Use of Gender While Addressing Early Attachment,Trauma, and Cross-Cultural Issues in a Cotherapy Group

This paper examines how early attachments, trauma, and transference are modified by cross-cultural issues in a group therapy setting. The paper focuses on preparation of an appropriate group after individual treatment, attention to composition in that group, and use of a female-male cotherapist team in helping two Latin American female group members work through their early traumas. In addition, the paper speaks about times when individual treatment with the group therapist of the opposite sex should be added. The paper emphasizes and clarifies how not to get caught up in cultural stereotypes and how the clinician needs to stay with the specificity of the person's organizing experiences.     

Mindful Parenting: a group approach to enhancing reflective capacity in parents and infants

In this paper, the process of ending therapy is likened to the ordinary developmental task of ‘letting go’ that parents have to undertake, to help their child to grow up. ‘Letting go’ is contrasted with the process of ‘holding’ the child in mind that is so central to the therapeutic and parental task Following thoughts about some of the external issues that play a part in the decision to end a child's treatment, this developmental perspective of psychoanalytic psychotherapy is discussed through a clinical illustration of the ending of a 5-year-old boy's treatment. Different strands of the therapeutic relationship as highlighted during the ending phase of therapy are distinguished and attention is drawn to the role of the ‘new relationship’ between therapist and child and how this differs from the transference relationship. Countertransference issues in their broadest form are also considered.     

Using Dreams in Treating Couples' Sexual Issues

The authors demonstrate use of couples' dreams in couple therapy for problems with intimacy, sexuality, and fidelity. Condensation, symbolization, and projective identification are mechanisms that result in the conversion of emotional and relational pain into sexual symptomatology. Dreams use similar processes to hide and at the same time convey emotional issues, and so dream analysis with couples is particularly useful in exploring and treating dysfunctional sexual relationships. As in individual psychoanalysis and psychotherapy, dreams in couple therapy express the transference. The authors show how dream analysis renders the couple's shared transference for resolution in the treatment process.     

The Group Psychotherapy Literature 1958

This study applies Kohut's self-psychology toward an understanding of the self-functions that membership in a religious cult group (Divine Light Mission) provides for the narcissistic personality. It is proposed that there exists a psychosocial fit between the appeal of the cult group's structure and process and the needs of the narcissistic personality. The cult group offers reparative and substitutive functions to the follower who seeks an idealized selfobject to stabilize a defective sense of self. The special relationship of the follower to the Guru bears a close resemblance to the “idealizing transference” which arises between certain narcissistic patients and their group therapist. The therapeutic use and misuse of the “idealizing transference” in group therapy is explored and suggestions are made for its appropriate clinical management.     

Silence and communication: nonverbal dialogue and therapeutic action

The subject of this article is silence as communication, with the starting point in the silences of three patients in treatment—in one of them his silences lasted up to a year. Silence is also seen as a specific dimension linked to speech, as the treatment of a third patient shows. The nonverbal interaction between patient and analyst is illustrated. This interaction led to a developmental process in each of the patients, characterized by fusion and separation processes, which included a development of three-dimensionality. The curative process taking place in each of the three, not through verbalisation but through the relation, is understood in the light of Modell's (1990) concept of “dependent/containing transference”. The treatment results demonstrate that the “dependent transference” is curative in itself when the therapeutic setting is maintained. The analyst's inner work during the dependent transference is described: a form of nonverbal participation and joint creativity in the intersubjective field.     

The symbolism of the story of Lot and his wife: the function of the 'present relationship' and non-interpretative aspects of the therapeutic relationship in facilitating change

Abstract The treatment of an adolescent patient preoccupied with thoughts about committing suicide is presented, as a vehicle for considering the significance of the 'present relationship' within the totality of the therapeutic relationship in bringing about change. The question of how the present relationship operates alongside the transference relationship is raised. It is argued that there needs to be more attention to and discussion of the therapeutic actions and re-enactments that take place within therapy which, while they may be viewed at times as unorthodox, may nevertheless be beneficial. This in turn can then lead to developments in technical and theoretical thinking based on clinical experience.     

Depth of Transference in Groups

An ongoing controversy in the field of group psychotherapy is whether transference regression is greater in groups than in individual treatment. There appears to be a general consensus that group behavior may be understood as operating on at least three levels—the conscious–rational, the oedipally determined transference, and the preoedipal maternal transference level. The more rational levels are associated with transference dilution, whereas the more primitive levels accompany transference intensification. Dilution occurs as a result of reality demands and inputs of the group situation and because of multiple targets of displacement. Transference intensification is a product of mutual stimulation, contagion effect, frustrating inputs, and support of the group theme. Certain patients benefit most from the dilution features of a group, and others profit most from intensification. The therapist's technique and the patient's pathology are the main determinants of which aspect gets emphasized and utilized.     

Combined therapy with borderline and narcissistic inpatients at the cassel hospital

An account is given here of a rather unorthodox approach to psychodynamic therapy with Borderline patients in part of the therapeutic community at the Cassel Hospital. ‘Combined therapy’ here refers to the setting in which one therapist sees patients in groups and individual sessions concurrently. The paper demonstrates the manner in which this approach brings to the fore the massive destructiveness and rage which so often lies at the core of these patients' difficulties. This is done by describing the development of the group over its first nine months. The therapist comes to be split in the patient's perception, the group sessions representing separation in all its most hated aspects rather than as a prerequisite for differentiation and growth. The resultant rage and destructiveness threaten to render the group unworkable and dangerous. The individual sessions, by contrast, represent a fantasy of being regressed and at one with the ideal mother. It is my belief that these difficulties can be contained only within a therapeutic community. The strength of this approach lies in the vivid reconstruction of a central conflict for these patients and corresponding potential for working through difficulties in the area of separation and individuation. It is also particularly effective in bringing the therapeutic community alive within the therapy. The discussion attempts to address some of the complex theoretical issues raised by the transformation of the transference in both settings which occurs when they are used together and with the same therapist.     

Holding in mind: Theory and practice of seeing children in groups

ABSTRACT The authors will describe their therapy group for children in a Child and Family Consultation Centre. They will discuss the rationale for this treatment. An account will be given of the group processes with special reference to different feelings as they emerge in the transference relationships. Issues concerning the dynamics of co-therapy will be addressed. The work on the ‘reflective function’ by Fonagy and Target, which the authors think is an important contribution to understanding the therapeutic process in the group, will be discussed.

What literature there is on group therapy for children suggests that it is an effective form of treatment. This article describes the way in which the children's issues come alive in group therapy and in this way can be addressed quickly, in comparison with individual therapy where the process is sometimes slower. It will be emphasized that structure and boundaries are essential for containment of children so that psychoanalytic reflectiveness can take place. This reflectiveness includes understanding of the group process as well as the inner world of the child.     

Psychoanalyse und Traumatherapie

The author is of the opinion that for patients with combined traumas of commitment and violence a psychoanalytical long-term treatment which takes into consideration the peculiarities of this group of patients will continue to be the therapy of choice. Special ??trauma therapies?? may be useful after acute traumas and in cases in which external conditions exclude psychoanalytical treatment. Depending on the situation of the individual case, though, specific modifications of the technique may be necessary, which possibly include proven specific trauma therapeutic techniques as parameters. Based on the parallelism of the economic aspect of the trauma and the aspect of object relationship, a decisive role in the therapeutic process befits the recognition of the traumatic reality and the working out of traumatic transference, which, however, must not traumatize under any circumstances. This is accompanied by the restitution of a good interior object, which only becomes possible within a frame giving security and support. The establishment and preservation of this frame may also be due to especially required parameters derived from trauma therapies, the psychodynamic significance of which must be analyzed with the individual patient. The author's approach is clarified by two case vignettes in which the theoretical reflections have led to very different technical procedures. The author comes to the conclusion that the psychoanalytical trauma therapy shows how therapeutic concepts aiming at an optimum result must still be tailored to the individual case.     

Counsellors’ and psychologists’ experience of working with male survivors of sexual trauma: a pilot study

A qualitative study was undertaken to enhance awareness of the therapeutic needs of the male survivor of sexual trauma through exploration of counsellors’ and psychologists’ experience of working with this client group. The participants were 32 counsellors and psychologists who work for an NHS Trust department. Interpretative Phenomenological Analysis was used to analyse the data which was gathered by means of a postal questionnaire. Six categories emerged from the analysis that highlighted prevalent experience. These were: (a) that the therapist's gender was important, (b) professional concerns, (c) the importance of the relationship, (d) transference/counter transference, (e) that male and female abusive experiences are the same and (f) attention to client's presenting problems. The main conclusions derived from these results and implications for practice are considered.     

Some Aspects of Group Dynamics

The authors examine the nature of the relationship between the group members and the group therapist and discuss the reasons underlying therapeutic frame failure. It is argued that competing viewpoints concerning the nature of the therapeutic relationship in group therapy have eventuated in problems in articulating a generally accepted frame definition. The authors propose a formulation of the frame for long-term groups that embraces therapist anonymity, total confidentiality, and neutrality. Finally, instances of frame violation are viewed as stemming from the therapist's need for objects, the attempt to forestall various types of transference, and the need to provide an avenue for the therapist's narcissism. Clinical material is used to illustrate group members' responses to therapist-induced frame failures.     

The therapist's pregnancy: Evocative intrusion

This paper is concerned with addressing the complex impact of the therapist's pregnancy on the analytic treatment process. The pregnancy is seen as intensifying the transference and countertransference material so that the therapeutic work becomes more strenuous as well as more fluid, with the potential for significant therapeutic change. The paper is divided into two parts. The first section attempts to conceptualise the meaning of the experience for the therapist and patient within the framework of psychoanalytic theory. Problems of technique and management resulting from the pregnancy are examined. One of the issues considered is the manner and timing of the patient's recognition of the pregnancy. The second section of the paper contains extensive clinical material illustrating the enriched transference and countertransference processes, and the access these allow to psychotic pockets of the personality, hitherto largely unavailable for exploration.