The Therapist’s Needs: Beyond Mutual Recognition

Abstract

As early as 1965, Harold Searles argued that therapists’ needs for healing and growth are part and parcel of their work with patients. Since then, the relational movement has corroborated this idea by articulating the healing function of treatment for both patient and clinician. In this article, the authors examine therapists’ needs that have been overlooked or those that have not been considered fully in the literature. Using various ideas related to the concept of what the authors call therapeutic freedom, this article argues that clinicians must strive to adopt a therapeutic vision that aims to loosen their own ties to safe, familiar modes of engaging with patients, particularly in moments of enactment or impasse. The authors elucidate these ideas with case material from their clinical work and show how embracing various forms of therapeutic freedom results in a type of mutual surrender on the part of both patient and therapist, creating opportunistic conditions that generate therapeutic action and new possibilities for the dyad.     

The Therapeutic Alliance in Multicultural Practice

Abstract

The therapeutic relationship rests on both an emotional bond with the therapist and a rational, “working” connection. Both dimensions of the alliance have relevance for multicultural clinical work. There have been many contributions to multicultural practice that emphasize either cognitive or emotional levels of the alliance. This paper uses both empirical studies and clinical papers to synthesize both the emotional and the rational perspectives on the multicultural alliance. Examples are drawn from literature, published case examples, and the author's own clinical practice.     

An extract of the analysis of the Monkey Puzzle Boy

Abstract

A client who wants his story to be made into a case history presents for psychoanalysis. An artist all his adult life, he expresses his sexual trauma through his art. His more recent artistic output is in the form of avant-garde video montages. The analysis stalls, becalmed by a failure to understand a circumcision event, a punishment for sexual expression. If Ferenczi and the Budapest school model learning from therapeutic errors, freedom of thought, sincerity, and experimentation, then this case history illustrates those. Real sexual trauma and a real circumcision event are entangled with fantasy and art in attempts to come to terms with them. The circumcision event was better understood with multiple readings of Carlo Bonomi’s work, which became part of the analysis. The wider Ferenczi community also became part of the story of the analysis, and in a kind of mutuality the analysis wants to make a contribution to that body of knowledge.     

Making the body (w)hole: A semiotic exploration of body modifications

Abstract

Cultural norms of attraction are dynamic and fluid, and are psychologically intertwined with acts of corporeal modification that use the body as signifier. These norms are expressed in various ways by individuals, but can be seen most plainly when they are worn on the body, such as with body piercing and tattooing. An intertextual understanding of how body modifications play a role in the integration of psyche and soma appears to motivate understanding of how individual choices are reflections of cultural mores. Psychodynamic and semiotic processes from case examples are provided to illustrate how individuals may move between affect and expressiveness as well as how reading the body as text can generate new understandings of an individual's decision to modify, thus allowing clinicians to better work with their modified clients.     

Chapter 5 Development,Psychopathology, and Brief Psychotherapy

Abstract

When using a developmental model to conceptualize curative factors in brief psychotherapy, the impact of the developmental process and the nature of the psychopathology presented by the patient must be taken into account. Both factors shape the therapeutic work. A case example of a young adult in the midst of developmental transition illustrates these issues.     

Soul pain and the therapeutic use of ritual

Abstract

This paper will explore the relationship between ritual and transformation. It will show how a therapist and a monk work together to create sacred spaces in which individuals can experience transformation of and through their personal histories, linking their past, present and future to address their soul pain through ritual.

It is illustrated with case studies which will demonstrate the phases of ritual work which are collectively important as part of the psycho-dynamic therapeutic process.     

Time's wingèd chariot: Short-term psychotherapy in later life

Abstract

This paper is concerned with the appropriateness of short-term psychodynamic psychotherapy with older adults, a client group which has historically been neglected in psychotherapeutic practice. Drawing on the case study of a fourteen-session therapy with a woman in her seventies, it is argued that brief exploratory work can be of particular value to people nearing the end of their lives. The nearness of death gives a special urgency and motivation to the work and a time-limited therapeutic contract mirrors the reality of having only a short time left. Making psychotherapy available to older people also represents an important valuing and validation of their experience.     

« La malléabilité du cadre thérapeutique comme support d’élaboration sur les terrains de l’aide internationale »

IntroductionIn the field of international aid, the projects set up, including psychological care systems, must respond to international and local requirements regarding their financing and sustainability. In these contexts, clinical questions intersect with those of the systems and culture. The traumatic dimension remains prevalent, and these contexts often must deal with multiple local and international requirements. These dimensions can influence the devices set up and their evolution.ObjectivesThrough feedback from an action-research conducted in Cambodia, we question the evolutions and adaptations of a therapeutic device with abused children.MethodFor one year, a device based on mediation was proposed for 10 children hosted within a local child protection NGO. We describe here its implementation and its evolution in the field.ResultsThe setting up of the system was a vector of different meetings. The adjustments were made in relation to the institutional context, the meetings with the local actors and the specificities of the clinic.ConclusionThe evolutions of the therapeutic device seem to signify the processes at play, both on the institutional and intersubjective scene. Regarding these field returns, the malleability of the therapeutic devices in these contexts seems to support the expression and the processual evolution, allowing a work of psychic elaboration.     

Emplotting the traumatic self: Narrative revision and the construction of coherence

Abstract

In this article we provide a constructivist‐narrative conceptualization of the origins and psychotherapeutic methods for treating trauma. We believe that the experience of trauma ensues when lived events outpace peoples’ abilities to emplot or narrate these events from the perspective of dominant life narratives. The sights, sounds, and smells associated with traumatic events preclude such emplotment. The therapeutic objectives of narrative therapy include finding ways to develop meanings for the trauma and subsequently to integrate these with the dominant narrative. Two case studies are provided to illustrate our conceptualization and therapeutic approach.     

Towards an understanding of the psychodynamic processes of the body

Abstract

Counselling clients frequently mention bodily symptoms, yet, within the therapy world, the body largely remains off-limits. This, in some part, is undoubtedly due to the prevailing issues around the touch taboo. However, the symptoms emanating from the body may well have profound psychodynamic meaning. This paper sets out to describe a psychodynamic perspective for how these symptoms may arise. Notions such as libido and preverbal theories, along with primal defence mechanisms, are used to show how the body becomes involved in unconscious processes. A case study is presented as illustrative of some of the psychodynamic concepts that may be implicated. It is argued that bodywork may help in providing a preverbal supportive environment from which a therapeutic alliance may develop, thus allowing for a verbalization of unconscious conflict.     

Strengthening the Strengths Perspective

Abstract

This article revisits the strengths perspective as conceptualized in social work practice. Although we find this perspective has value and utility for practitioners, we identify areas where the strengths perspective could be enhanced and augmented by integrating the contemporary relational approach exemplified by Paul Wachtel's cyclical psychodynamics. Specifically, we explore his concepts of therapeutic communication and use of language, including interventions that affirm client strengths such as reframing, searching for variations and exceptions, and reconceptualizing how transference impacts the therapeutic action. We illustrate our view with a case vignette, advocating that Wachtel's integrative approach provides a new context for psychodynamics in current social work practice.     

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.     

Affect Regulation and Attachment Focused Treatment of a Husband with Obsessive-Compulsive Disorder and His Wife

Abstract

In this paper, the author presents an overview of Obsessive-Compulsive Disorder (OCD), an affect regulation and attachment framework for treatment of couples and families, and a case study illustrating how this framework can be used to work with a couple in which the husband has OCD symptoms.     

A psychodynamic perspective on early childhood trauma in an adult: A case study

Abstract

This paper uses a long-term case to illustrate, from a psychodynamic perspective, a number of issues arising in working with an adult survivor of early childhood trauma. The paper takes an overview of the case study, identifying issues which are inextricably interwoven in the client's experience of trauma, and which impact on the working alliance. The therapeutic relationship forged with the client is discussed in terms of its intrinsic successes and failures together with the implications of early traumatic experiences for the termination of counselling.     

From Knowing to Discovering: Some Suggestions for Work with Anorexic Patients

ABSTRACT

In this article I offer some technical suggestions for psychoanalytic work with anorexic patients. Although focused on an outpatient setting, certain parts of the article will also have utility for inpatient work. As an outpatient therapist working with an anorexic patient, especially in the acute stages of the illness, there are case management demands that need immediate attention. The setting up the particular frame is required to augment the therapeutic work. The most urgent pressure felt by the clinician is the precariousness of the patient’s physical health. This can be experienced as if there is a gun to the head of the therapist. This deathly force must be carefully and constantly grappled with, and particularly so in the most symptomatic stages of the illness. The clinician must work with a patient who might die at any time, yet an anorexic patient cannot be managed the way a suicidal patient would be. The question of technique in this situation is a complex one. Above all, the patient must be met where s/he is. Notwithstanding the uniqueness of each patient there are some specific themes that often arise in the acute stage of the illness. Certain technical suggestions are offered.     

The Ward and the Womb: An Integrated Therapeutic Approach for Treatment Resistant Adolescents

ABSTRACT

In mental health settings, we often meet traumatized and volatile youth who resist treatment and do not respond to engagement attempts. For such patients, the treatment refusal may be a representation of their level of personality organization; it can represent difficulties to relate to others, to regulate affective experiences, and to integrate different self-states. Using a case study of a treatment resistant adolescent in residential care, I discuss the limitations of engagement techniques with patients at the lower end of personality organization and argue that engaging “difficult to treat” adolescents requires a clinical shift from the therapeutic encounter to the development of a system-based “holding” environment. I present a modified intervention model that integrates psychodynamic formulation of personality development with process-oriented systemic work. The model described emphasizes the role of the therapist as the initiator and facilitator, helping to construct a coherent and attuned environment within the residential care system. Through case vignettes, I provide examples for the clinical shift from the therapeutic encounter to the environment of the ward and demonstrate how developing a holding environment can overcome engagement barriers and support the development of the patient’s ego capacities, sense of self, and object relations.     

Chapter 6 Developmental Perspectives in Brief Treatment of Gay Youth

Abstract

This report explores representative dilemmas of gay youth in the transition from late adolescence to young adulthood and shows how brief treatment may facilitate efforts to work toward greater authenticity in sense of self and identity, revise maladaptive relational patterns, and strengthen coping capacities. It presents the case of an 18-year-old male who was seen in supportive psychodynamic treatment for 13 sessions in a university counseling service. Developmental and relational deficits, rooted in a stigmatized identity, perpetuated problems in functioning. The relational functions and supportive elements of the therapeutic process are emphasized in discussion of curative factors. Establishment of the selfobject bond with the therapist strengthened self, facilitated coping, and improved social functioning. The author emphasizes the importance of considering the impact of internalized homophobia and self-alienation in assessment of functioning and establishment of treatment goals.     

Jean-Luc Marion: the reinscription of heteronormativity into postmodern theology

ABSTRACT

Since the “theological turn” in continental philosophy, theologians have regularly turned to phenomenology as an authentic opening to a new mode of theological discourse. Yet, when these theo-phenomenological discourses turn to the questions of sexuality, gender, and love they often fail to live up to the radical opening promised by this turn. Taken as a case study, the work of Jean-Luc Marion is emblematic of this failure. While many of his insights might offer new openings for theological thought, his phenomenological speculations nonetheless often merely serve to re-inscribe a traditional, even reactionary heteronormativity into the heart of postmodern theological thought. In fact, it is not uncommon to catch his work offering a denigration of the body, presupposing a determinately male subject, and foreclosing the very possibility of non-heterosexual love. This critical examination of Marion’s account of sexuality shows that even the most radical phenomenological theology needs the ideological interruption of queer theory.     

Spontaneous Moments and the Domain of Non-Verbal Communication

Abstract

This paper investigates the impact of non-verbal interactions and spontaneous encounters on the therapeutic process and on a client's structural and behavioral patterns. The following case vignette concerns a client who presents with a pattern of non-verbal relational schemas based on his early traumatic experiences. The non-verbal and verbal role reenactments that unfold between client and therapist will be examined from an intersubjective, dialogical and self psychological perspective. Finally, the paper will explore how important therapeutic shifts may occur by attending to and working through these non-verbal aspects of the treatment, leading to new relational structures.