A plea for greater recognition and appreciation of our group members' courage

Courage-a mental act that involves a decision to face and deal with emotional pain as honestly as possible without any guarantee of a positive outcome-resides at the heart of the therapeutic alliance and the work of psychodynamic group therapy. The author's experience suggests that group therapists tend to take for granted or underestimate the courage required to join and participate in a psychodynamic therapy group. Written from the perspective of self-psychology, this article provides a theoretical rationale for courage recognition as a central and crucial leadership function. Examples of courage are presented and contrasted with behaviors that appear courageous but are not. A detailed case example discusses the courage it takes for dyads to work through reciprocal negative transferences. Suggestions are offered to assist the group therapist in recognizing and calling attention to courageous behaviors. The author discusses some of the pitfalls of our profession's preference for value-free language and then shows how and why the occasional and judicious use of non-neutral language, courage being an example, can facilitate and deepen group work.     

The development of an evidence-based treatment: Regulation-Focused Psychotherapy for Children with externalising behaviours (RFP-C)

There is a critical need for the development, evaluation and implementation of evidence-based psychodynamic treatments for children and adolescents. Currently, there are no empirically supported, manualised psychodynamic treatments for children and adolescents with disruptive behaviour problems. The field of manualised psychodynamic treatments with measurable equivalence or superiority to other established forms of psychotherapy is in its nascent stage. This paper details a novel, manualised, time-limited psychodynamic treatment approach for children who manifest disruptive behaviours and emotional dysregulation. Regulation-Focused Psychotherapy for Children (RFP-C) conceptualises children’s disruptive and acting out behaviours as expressions of maladaptive emotion regulation. Externalising symptoms are conceptualised as attempts to defend against painful emotions and thus protect the child from disturbing feelings such as sadness, shame and guilt. This paper provides the theoretical basis for the treatment approach and through the use of a clinical example demonstrates the systematic application of RFP-C in a single case.     

Narrative inquiry in sport and exercise psychology: What can it mean,and why might we do it?

ObjectivesNarrative inquiry is one form of qualitative research that is burgeoning within the human sciences. However, in sport and exercise psychology little attention has been given to this approach. In this article, we seek to rectify this situation by offering an understanding of what narrative inquiry can be.ResultsIn order to begin to better understand what narrative inquiry as a methodology can be, and gain some theoretical purchase on a difficult field without aiming for a final answer, we first define narrative. Next, a distillation of guiding assumptions and characteristics are offered. Finally, some reasons as to why narratives may be of benefit for the field of sport and exercise psychology are highlighted.ConclusionNarrative inquiry is a useful and important way of theorising and doing research in the domain of sport and exercise psychology. It should not, however, be taken up or practised simply because it is new or fashionable. Informed, principled, and responsible choices must be made by researchers and applied professionals about why and when they might engage with narrative inquiry should they wish to do so.     

The double-edged pen: Omnipotent fantasies in the creativity and addictions of Stephen King

The legendary debate over whether a connection between creativity and addictions exists is one that is shrouded in mystery and intrigue, but also one that continuously returns to the circuitous metaphor of the chicken and the egg. In an effort to better understand nuances in the relationship between creativity and addictions, this paper examines the life of Stephen King, and the omnipotent fantasies from which both his creative processes and addictive behaviours emerged. Since the early twentieth century, psychodynamic thinkers have highlighted omnipotent fantasies as a psychological force driving creative processes as efforts towards personal transformation. Similarly, numerous psychodynamic theories have highlighted omnipotent fantasies as playing a cardinal role in the psychological processes that propel substance abuse. And yet, the construct of omnipotence has yet to be examined as a theoretical bridge to bind such theories of creativity and substance abuse together. While fostering personal meaning and self-transformation when manifested in his creative writing processes, omnipotent fantasies have also lead Stephen King down a precarious path of addictive behaviours. Through a narrative analysis of the life of Stephen King, who has written in great depth about both his creativity and substance abuse, I will illustrate how omnipotent fantasies often shape and foster both healthy, creative processes towards growth and maladaptive, addictive impulses towards self-destruction.     

Psychoanalytische Neurosenlehre: Eine Einführung (Psychoanalytic Theory of Neuroses. An Introduction)

Abstract

Courage–a mental act that involves a decision to face and deal with emotional pain as honestly as possible without any guarantee of a positive outcome–resides at the heart of the therapeutic alliance and the work of psychodynamic group therapy. The author’s experience suggests that group therapists tend to take for granted or underestimate the courage required to join and participate in a psychodynamic therapy group. Written from the perspective of self-psychology, this article provides a theoretical rationale for courage recognition as a central and crucial leadership function. Examples of courage are presented and contrasted with behaviors that appear courageous but are not. A detailed case example discusses the courage it takes for dyads to work through reciprocal negative transferences. Suggestions are offered to assist the group therapist in recognizing and calling attention to courageous behaviors.

The author discusses some of the pitfalls of our profession’s preference for value–free language and then shows how and why the occasional and judicious use of non–neutral language, courage being an example, can facilitate and deepen group work.     

Indikation zur strukturbezogenen Psychotherapie

The distinction of conflict processing and structure promoting psychotherapeutic approaches in the psychodynamic field is now common knowledge and has now been incorporated into the guideline comments. The differentiation of treatment presupposes theoretical knowledge of the dynamics of conflict and structure and corresponding thorough initial diagnostics. Based on these foundations an appropriate focus of therapy can be agreed with the patient and the therapy target can be set. This focussed working towards a joint target is especially important for psychodynamic psychotherapeutic treatment, which is of limited duration. The actively accompanying therapeutic process differs from older assumptions that positive developments on the foundation of a therapeutic relationship occur quasi automatically but possibly need a long time. Aspects of the treatment technique and the therapeutic attitude, estimation of the therapeutic development and typical age-related modifications in adolescents and older persons are discussed.     

Gender: A critical factor in a couples group

Couples group therapy should be considered as a primary treatment for marital couples whose dysfunctional interaction is rigidified and chronic. A gender-linked perspective for treatment is developed which expands a psychodynamic approach underscoring power as one of the central issues in marital conflict. Clinical vignettes from couples groups illustrate this model. A gender orientation facilitates the psychodynamic group process, decreases unrealistic expectations of the spouse, and encourages greater acceptance of male/female and individual differences. In this setting, individuals are able to develop new and more functional modes of interaction with their spouses, which generate an increased sense of empowerment.Excerpts from this paper were presented at the American Family Therapy Association meeting in Montreal, 1988.The authors gratefully acknowledge the helpful comments of Henry Grunebaum, M.D., and Fred Sander, M.D.     

Can anybody hear me? Reacting to pressures from psychotic states of mind

In this paper material is presented from supervision groups run for nurses and other mental health professionals. The patients presented to the group all came from different mental health settings and suffered from psychotic states of mind. In this paper I will argue that the psychodynamic model can help nurses and other front‐line mental health professionals in their understanding of psychotic process. Nursing staff, in particular, are with their patients over long periods of time and see them in different settings. The psychodynamic model can be helpful in giving mental health professionals a language for describing their experiences of, and interaction with, their patients. The psychodynamic model can also provide a dynamic picture of the patient's problems over time. This type of assessment and thinking, which includes an understanding of the dynamic process involved in psychosis, can then stand alongside the medical model.     

The empathizing–systemizing (E–S) model of autism and psychoanalytic theories of truth,play and symbolization

Little psychoanalytic material or theory features today in psychological work on autism and autistic traits and vice versa. Baron-Cohen's (2003) empathizing–systemizing (E–S) model of the autism spectrum posits two main clusters of autistic features: those surrounding impaired empathy, and those surrounding heightened systemizing behaviours. (Baron-Cohen, 2009) speculates that the common root of these two clusters is the individual's concept of truth. Psychoanalysis has addressed the related issue of internal and external reality since (Freud, 1897) differentiated ‘psychic’ from ‘historical’ truths. This could be of interest to those espousing the E–S model from a cognitive paradigm, as a ‘truth’-oriented cognitive style in autism may develop interdependently with the individual's experience of internal and external realities. Psychoanalysis has developed further ideas of relevance to the E–S model surrounding play and symbolization, the latter being an often-overlooked aspect of Wing and Gould's (1979) triad of autistic features. Seen from a psychodynamic perspective, the E–S model might provide a means to increase therapists' awareness of milder autistic traits amongst service users and analysands. Equally, it could offer a tool to structure empirical research into psychodynamic therapy with autism spectrum conditions.     

From Couple Therapy 1.0 to a Comprehensive Model: A Roadmap for Sequencing and Integrating Systemic,Psychodynamic, and Behavioral Approaches in Couple Therapy

Couple therapy is a complex undertaking that proceeds best by integrating various schools of thought. Grounded in an in‐depth review of the clinical and research literature, and drawing on the author's 40‐plus years of experience, this paper presents a comprehensive, flexible, and user‐friendly roadmap for conducting couple therapy. It begins by describing “Couple Therapy 1.0,” the basic conjoint couple therapy format in which partners talk to each other with the help of the therapist. After noting the limitations of this model, the paper introduces upgrades derived from systemic, psychodynamic, and behavioral/educational approaches, and shows how to combine and sequence them. The most important upgrade is the early focus on the couple's negative interaction cycle, which causes them pain and impedes their ability to address it. Using a clinical case example, the paper shows how all three approaches can improve couple process as a prerequisite for better problem solving. Additional modules and sequencing choice points are also discussed, including discernment counseling and encouraging positive couple experiences.     

When theory abandons us – wading through the 'swampy lowlands' of practice

This paper uses three clinical examples to illustrate the experience of feeling abandoned by theory – times when no one model has sufficient signposts to show the way. Therapy is considered to be an endlessly creative interpersonal encounter, to which the client brings the major resource for change. It is argued that the therapist is influenced by worldview, values and beliefs, and personal style, as well as by theoretical model. Further, it is suggested that there is a need to acknowledge and investigate the limitations of therapy. An argument is made for 'going beyond the model', for seeking an ethical practice based on what our clients tell us is important, and for sharing across models the common dilemmas and goals of therapy. Clinicians are encouraged to articulate their own 'swampy lowland' principles of practice.     

Integrating empirically supported therapies for treating personality disorders: a synthesis of psychodynamic and cognitive-behavioral group treatments

Abstract This paper describes the theoretical foundations and components of an intensive group treatment program for individuals diagnosed with personality disorders. The Chrysalis Community Day Treatment Program integrates aspects of three empirically supported therapies: Transference-Focused Psychotherapy and Mentalization-Based Therapy, both psychodynamic psychotherapies, and Dialectical Behavior Therapy, a cognitive-behavioral therapy. Each of these modalities is structured for the treatment of individuals suffering from the symptoms of borderline personality disorder, and each of the treatments addresses problems that occur across a wide spectra of beliefs, capacities, and behaviors. The program is comprised of expressive, psycho-educational and skills-training groups, and participants attend three days per week, for 15 weeks. Preliminary evaluation is promising, reflecting decreases in self-injurious behavior, suicide attempts, psychiatric hospitalizations, and psychiatric symptoms at a one-year follow-up.     

The use of safety behaviours to manage intrusive memories in depression

Cognitive models of clinical disorders conceptualise cognitive and behavioural safety-seeking behaviours as central to symptom persistence because they prevent disconfirmation of key maintaining beliefs. Despite growing evidence of the role of negative beliefs about intrusive memories in depression, it remains unclear why such beliefs persist. Accordingly, we examined whether safety behaviours in response to unhelpful beliefs about intrusive memories might play a role in their maintenance. Eighteen high dysphoric (i.e., BDI-II12) individuals who reported an intrusive negative autobiographical memory in the past week completed a battery of measures about their memory, associated negative beliefs and safety behaviours adopted in response to their beliefs. The most commonly endorsed beliefs reflected themes of wanting to control memories (e.g., ‘I should be able to rid my mind of this memory’) and self-deprecation about experiencing them (e.g., ‘Because I can’t control this memory, I am a weak person’). The beliefs prompted a range of safety behaviours, with cognitive distraction being the most common. The findings demonstrate that safety behaviours are common in response to maladaptive beliefs about intrusive memories. Treatment developments in this area are needed, and should incorporate strategies to challenge beliefs about memories, reduce the use of safety behaviours, and promote processing of intrusive memories.     

Is there anybody there? A psychodynamic view of panic attack

The effectiveness of cognitive-behavioural therapy is frequently cited when adopting this model as treatment of choice for panic attacks and anxiety disorders. However, Frank (1974), in discussing treatment effectiveness and patient compliance, argues that 'the more closely the conceptual framework of therapy fits that of the patient, the more readily he can accept it' (p. 370). In the following process analysis, my client's clear requirement for an exploratory approach meant that it was a psychodynamic understanding of the complex aetiology of her panic attacks that ultimately produced improved coping skills and a subjective sense of improvement for her. Process analysis has been chosen to illustrate the theoretical base, clinical impact and experiential immediacy of psychodynamic work; attention is drawn to the importance of transference and countertransference experiences in the choice of clinical interventions which tally with the client's sense of internal reality.     

To be in touch

This study examined the constellation of interaction structures – repetitive patterns of interactions between patient and therapist over the course of treatment – that emerged in the psychodynamic therapy (PDT) of a child diagnosed with borderline personality disorder and treated by two doctoral student therapists. Identification of these interaction structures can inform therapists of what might be expected from patients with particular symptom or behaviour patterns and how interactions change over time. This study also examined each session’s adherence to three session prototypes: PDT, cognitive-behavioural therapy (CBT) and reflective functioning (RF) process. The Child Psychotherapy Q-Set (CPQ) is a 100-item instrument that assesses the processes within a single psychotherapy session. Items reflect a wide range of therapist attitudes and behaviours, patient attitudes and behaviours and interactions between therapist and patient. Experts used the CPQ to define PDT, CBT and RF process session prototypes. The results suggested that four distinct interaction structures could be identified and that their constellations differed between the two therapists and also differed over time within each treatment. Therapists were more structured and accommodating early on in their treatments and more interpretive later. Prototypical PDT process was more prominent in the sessions than RF process, which in turn was more prominent than CBT process. Unique therapeutic processes are at work in every dyad, despite holding the patient and theoretical orientation constant. An effective treatment in one dyad might not work in another due to therapist-specific and dyad-specific effects.     

Three modes of psychotherapy and their requisite core skills

The field of psychotherapy suffers from the lack of an integrative meta‐perspective on the large variety of existing psychotherapies and on the therapeutic skills involved. In the present paper, it is suggested that the development of a more comprehensive view of this field may be facilitated if we differentiate between three modes of psychotherapy, which require different therapeutic core skills: (a) an educational mode, which requires teaching skills; (b) a reparative mode, which requires analytic‐conceptualising skills to identify some kind of disordered functioning, in combination with specific relational‐technical skills to repair this dysfunction; and (c) a developmental mode, which involves engaging in a therapeutic relationship with patients to facilitate their personal growth, and which requires non‐directivity skills. In addition, some therapeutic skills (e.g., awareness and communication skills) may be more or less important in all modes of treatment. Concrete manifestations of the three different modes of psychotherapy are discussed in terms of five different theoretical perspectives on psychotherapy: the common factors, the humanistic‐experiential mindfulness cognitive‐behavioural (CBT) and psychodynamic perspective. The common factors model is criticised as being insufficient in several respects. Finally, it is argued that if personal therapeutic skills are essential to the effects of psychotherapy, then empirical research on psychotherapy needs to be re‐oriented towards a person‐oriented study of therapist skills in action, in the context of a study of the interaction between therapist and patient.     

Brief Communications

Abstract

This paper describes the theoretical foundations and components of an intensive group treatment program for individuals diagnosed with personality disorders. The Chrysalis Community Day Treatment Program integrates aspects of three empirically supported therapies: Transference-Focused Psychotherapy and Mentalization-Based Therapy, both psychodynamic psychotherapies, and Dialectical Behavior Therapy, a cognitive-behavioral therapy. Each of these modalities is structured for the treatment of individuals suffering from the symptoms of borderline personality disorder, and each of the treatments addresses problems that occur across a wide spectra of beliefs, capacities, and behaviors. The program is comprised of expressive, psycho-educational and skills-training groups, and participants attend three days per week, for 15 weeks. Preliminary evaluation is promising, reflecting decreases in self-injurious behavior, suicide attempts, psychiatric hospitalizations, and psychiatric symptoms at a one-year follow-up.