The preoedipal patient and the pregnancy of the therapist

This article is a contribution to the sparse literature on the pregnancy of the therapist. The therapist's pregnancy is viewed as an event that can facilitate progress for some female patients with preoedipal problems. In these cases, it provides a dramatic opportunity to address developmental difficulties, including separation problems and inadequate ego ideal formation, through the analysis of the self-object transference. Clinical material illustrates the working through of these issues for a patient in whom the therapist's pregnancy was stressful but not traumatic. Therapeutic interventions were aimed at fostering greater differentiation between self and object. A contrasting case is also examined in which the pregnancy was felt to be traumatic and feelings about it largely denied. However, underlying transference issues were eventually addressed.     

The internal world of the juvenile sex offender

This paper explores the consequences of the therapist's two successive pregnancies on a female patient. The second pregnancy was felt to be particularly difficult and disturbing. One of the central reasons was that after the patient's birth, the mother had a disabled child, followed by a stillbirth and soon after that the father left to marry another woman. Using Freud's concept of deferred action I will argue that my second pregnancy revised these earlier traumatic experiences.

The patient seemed to have incorporated and identified with a damaged maternal object that at the time of the original trauma was left husbandless, depressed and suffering from panic attacks. Although the therapist's healthy pregnancies seemed to reassure temporarily, it was difficult for the patient to hold onto a view of a helpful and productive therapist, one separate from this damaged internal mother. This was particularly so during and after the second pregnancy, where there was a marked absence of an idea of a third object, a father or a husband, who could help the patient deal with this pregnancy, her only escape was to retreat and act out.

The acting out was in part identification with a fleeing father and in part a defence against the absence of such a third object, so that it was used as a way of avoiding claustrophobic feelings of being trapped with the damaged mother. Her feelings of triumph then produced much guilt, and impeded reparation.

Another important issue that two successive pregnancies bring, are feelings of guilt in the therapist for exposing the patient to two major disruptions. In this patient's case it exacerbated the internal reality of a damaged maternal figure.     

Freud

The author explores the evidence-base and selection criteria for a short-term supportive dynamic approach for patients whose psychological mindedness and quality of object relationships is low. Illustrating this approach with a case example he outlines the central features of Supportive Dynamic Therapy. He describes a psychodynamic conceptual and developmental framework that can be used to guide the therapist's interventions and responses, and modulate the patient's anxiety. A dynamic focus presented in the form of a central issue is shown to have a significant function both in containing the patient's anxiety, and in giving shape to the therapist's efforts to support the patient's ego-strengths and adaptive abilities. The therapeutic work can be seen to result in an alteration in the trajectory or reiterating pattern of the patient's life.     

The absent psychotherapist

This paper explores the effects in psychotherapy of the therapist's sudden and unexplained twelve-week absence, caused by a pregnancy that was threatened and ultimately miscarried. The anxieties of the patients stirred up by the absence and the therapist's own countertransference difficulties are considered.     

Addictive states of mind

This paper explores the meaning of the pregnancy of the therapist as a challenge to the maintenance of the setting for therapy. The patient I shall describe was born ‘black’ in a ‘white’ family and was thus a challenge to her father's sense of paternity and her parents as a couple. She was the visual evidence of an infidelity. The problem had been denied in various ways, going as far as the attempt to deny her very existence. The therapist's pregnancy signified a betrayal of the ideal of a stable setting which was compounded by an earlier absence through illness. This ‘breaking of rules or promises' was then the setting for a re-working of the patient's story.

Setting, it is argued, can helpfully be seen as the mental space created by the partnership within the therapist between maternal and paternal relating to the ‘baby’ of the therapy. This enables a sense of negotiation and relationship in the creation of setting, which can include disruptions and other babies. At the same time the therapy had to work with a fundamental issue of illegitimacy or lack of belonging and the therapist's response to this. The ‘rules' of setting are a means to ensure a place to belong or attach to, but this work emphasized ‘setting’ and belonging as issues of relationship supported and enabled by our rules of engagement, but not reducible to them.     

Saudi therapists' lived experience of self-awareness

Self-awareness and self-reflection in psychotherapeutic processes have been critical components for effective counselling and psychotherapy. However, little qualitative research in Saudi Arabia has been conducted that aims to explore the therapist's subjective experiences of the self in their professional work. Therefore, the purpose of this phenomenological study was to understand the therapist's self-awareness within psychotherapy, by focusing on the therapist's lived experience of self-awareness and exploring how therapists recognise themselves as an integral component of the therapeutic relationship. Semi-structured interviews were conducted with six experienced and accredited psychologists with at least three years of clinical experience, and the qualitative data were analysed using interpretative phenomenological analysis (IPA). Five superordinate themes emerged from the data; that is, development of the professional self, use of self, self-oriented, supervision and experience. This study provides an understanding of the therapist's self in psychotherapy, as it shows that self-awareness is important for therapists to manage their feelings, thoughts and behaviours in meeting with clients and that it is a valuable resource for a therapist to become aware of and reflect upon the process within oneself. This understanding is integrated into the training programmes in counselling psychology, especially in the areas of self-awareness and personal development.     

Intimacy in the Face of Catastrophic Illness

SUMMARY

This is a therapist's story of her battle with life-threatening breast cancer and the impact of that illness on the intimacy bond with her husband of thirty years. She reviews the year of treatment, noting the couple's connections at various points in the process of dealing with the disease: the diagnosis, the treatment and the aftermath. Facing life-threatening illness can drive a couple apart or draw them closer together, but whichever it does, it is a loss of innocence about the very real presence of death and its impact on our daily life in relationship.     

Threats of suicide

For patients in treatment, how do suicidal feelings emerge, how do we judge the seriousness of suicide threats and what do we do? The literature on suicidal thinking, suicidal threats and suicidal acts is reviewed as well as some of the accumulated statistics for adults, adolescents and children. Some treatment principles and countertransference reactions are presented. The values of the therapist and the therapist's feelings toward death are seen as coloring the therapist's reaction to suicidal patients.     

Primary Process Communication

An unorthodox view of the function of primary process is presented with a view to enlarge, rather than diminish Freudian assumptions. One of the basic tenets of Freudian hypothesis was the supposed lack of influence of outside experience upon primary process functions. Yet we see demonstrated on a daily basis that primary process cognition is at work in any human interaction or experience. The mental structures of the self in interaction with the nonself is constantly monitored, added to, or subtracted from during contact with others. It is a prereflective mode that does not immediately rise into awareness. We give meaning to all interactions without necessarily reflecting upon them or even clarifying them to ourselves. Without allowing for such meaning to be integrated, we would lose or misinterpret large portions of our daily interactions. Flaws in communication occur every day and are demonstrable particularly in therapy when therapists are not attuned to their patients' emotional needs. It is demonstrated that nonverbal avoidance behavior of disturbed infants is the precursor for disturbed object relations of adults. Therefore, it makes no sense to interpret unconscious meanings—there are none. The difficulty lies in the inter-subjective realm and serves defensive modes. However, if patients present an inauthentic self, it is often difficult to decide if one is indeed in the presence of such a maimed self. The therapist's countertransference aids in detecting inaulhenticity. Ever-present, unconscious meaning analysis must be brought into consciousness by the therapist in order to further the therapeutic process.     

The role of community and narrative in the work of the therapist: A post-modern theory of the therapist's engagement in the therapeutic process

This article presents a theory which suggests that therapists engage in therapeutic relationships seeking the (re) formation of their client's self-narratives according to certain normative resources. The notion of therapy as a process of narrative (re)formation is discussed, and the nature of the resources that guide the therapist's work are described as macronarratives, beliefs and a vision of the good life. This theory is explored in relation to Carl Rogers' therapeutic encounter with the client Gloria, and the article concludes with a discussion of the wider implications of this theory for those interested in therapy.     

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.     

Empathy as dialectic imagination

Abstract

The importance of relationship processes for humanistic and psychodynamic therapists makes empathy a critical concept in psychotherapy. Experimental work suggests that learning occurs only when the subject is actively and cooperatively engaged in the learning process. Similarly, psychotherapy is only effective when the client is willingly active in the therapeutic process. A crucial aspect of the therapist's activity is empathic imagination, defined here as the use of “dialectic” thinking capacities‐the recognition of conceptual alternatives in a given situation. These processes are at the heart of a humanistic view of agency. The therapist's use of this capacity allows imaginative projection into aspects of the client's experience, helping the client to feel understood in the relationship and emboldened to consider new possibilities in life.     

Between the Ability to Imagine and Actually Seeing: The Intersubjective in Reclamation

When working with severely damaged, neglected, and deprived patients, the analyst relies on the faith that the intersubjective analytic space can be the site of a live relationship. In this regard, the unique technique of “reclamation” might be used with patients in a moment of imminent danger or of a sense of psychic death and involves an active response to the sense of emergency in countertransference. Reclamation is based on the analyst/therapist's ability to conduct intersubjective dialogue between the various spaces of internalized object relations, and the author attempts to extend the possibility of its technical application by considering reclamation as intersubjective.     

INCREASING THE INDEPENDENT RESPONDING OF AUTISTIC CHILDREN WITH UNPREDICTABLE SUPERVISION

We investigated the role of predictable versus unpredictable supervision on the independent task responding of three autistic children. In a predictable supervision condition, the therapist was present in the setting for a regular period of time and then was absent for the remainder of the session. In an unpredictable supervision condition, the therapist's presence was scheduled on a random, intermittent, and unpredictable basis throughout the session. The multiple baseline analysis showed that the unpredictable supervision produced much higher levels of on-task responding during the therapist's absence for all three children. Analysis of work completed during the therapist's absence also favored the unpredictable supervision condition. The results are discussed in relation to the literature on generalization and educational practice.     

Love in the counter-transference: The uses of the therapist's excitement

SUMMARY

The psychoanalytic tradition has always had difficulty with the question of the therapist's sexual feelings toward the patient. This paper traces that difficulty: from Freud's original struggle to replace moralism with a psychoanalytic mode of understanding, to the more recent literature on countertransference which still seems particularly averse to the possibility of the therapist's sexual experience. By way of a discussion of a psychoanalytic psychotherapy, I argue for the sometimes central therapeutic role of the therapist's experiencing, and then containing, excitement.     

Countertransference disclosure and the asymmetry/mutuality dilemma

No single issue illustrates more clearly the interpersonal therapist's struggle between asymmetry and mutuality than countertransference disclosure. On a theoretical plane, all versions of interpersonal psychoanalysis share a comfortable tolerance for a central dynamic tension between the mutual influence of the participants and the asymmetry inherent in a relationship that emphasizes understanding the motivations of only one participant. This same marriage of concepts has, however, been a source of considerable confusion within the area of technique. The practitioner is charged with the technical implementation of the theory and must define the line between asymmetry and mutuality in everyday interactions with patients. Difficulty tolerating the ambiguity caused by the tension between asymmetry and mutuality results in the understandable urge to seek a definitive and unwavering position on countertransference disclosure.

Dimensions of the therapist's struggle include complex decisions concerning the primary unit of study (patient or relationship), the sequence of exploring new and old object transference experience, the use of disclosure with or without concurrent understanding, an assessment of the patient's capacities to tolerate disclosure, and, lastly, the initiation and frequency of disclosure interventions. An integrative perspective on the tension between mutuality and asymmetry allows the dialectical relationship between these principles to reach a constantly evolving equilibrium unique to each patient based on the moment of clinical interaction.     

The Edge of Chaos: Enactment,Disruption, and Emergence in Group Psychotherapy

The author outlines his approach to the theory and practice of group psychotherapy. The emphasis is on therapy by the group rather than therapy in the group. The therapist's task is to help the group itself become the agent of change. The group is conceived as being composed of many multiple selves. The process of group psychotherapy unfolds through enactments that involve the whole group and the group therapist entering into the grip of repetitive and unmentalized self-states. These enactments are resolved when the group members, with the therapist's help and containment, can access alternative self-states that allow for new and unformulated experience to emerge. This dialectical movement between the rigid “familiar chaos” of enactment and the reflective and related working through is compared to the dynamic systems theory articulation of the tension between rigidity and chaos captured by Kauffman's notion that “life exists at the edge of chaos.” A group session is described that involves a painful enactment. It illustrates how the therapist allows the enactment to unfold by holding and containing intense affect and how the group members are helped to find their own meaning and new experience in interaction with each other.     

Therapist attitudes and countertransference as predictors of professional quality of life and burnout among psychotherapists

This study aimed to examine the role of attitudes towards psychotherapy and countertransference dimensions as predictors of professional quality of life and burnout among psychotherapists in Iran. Participants were 259 psychotherapists who worked in mental health centres in Tehran (Iran), and they completed the Professional Quality of Life questionnaire, the Therapist Response Questionnaire and the Therapist Attitudes Scale. Professional quality of life was associated with countertransference dimensions and attitude towards psychotherapy. This study concludes that psychotherapists can benefit from working on their specific countertransference issues and re-evaluating their basic attitudes towards psychotherapy to achieve the highest levels of professional satisfaction. Culture may play a role in a specific therapist's attitude and difficulties in addressing certain aspects of countertransference.