Management of a dying patient in group therapy

In the last few years there has been an increased interest in the psychosocial aspect as well as in the therapeutic needs of the dying patient. Although much has been written about the treatment of the dying patient, most of these works were done in the individual setting, either with out-patients or with hospitalized patients. However, relatively little attention has been paid to the treatment and management of the dying patient in a group therapy setting. In this paper the authors describe their experience in working with a dying patient in an ongoing therapy group. The effect on the group, on the individual patient and on the therapist are discussed. Moreover, the conflicting needs of the individual patients versus those of the remaining group members are discussed and compared to similar reports from the group therapy literature.     

Dilemmas and countertransference considerations in group psychotherapy with adult children of alcoholics

This article will explore special leader issues that emerge in psychodynamically oriented therapy groups with adult children of alcoholics. Particular focus will be on countertransference feelings that get stirred up in group leaders and techniques for dealing with some of these special dilemmas. Specific issues include (a) assumption of sameness between the therapist and the patient (the therapist assuming that he or she "understands" because of having also grown up in an alcoholic family); (b) the "will to restore," which may be destructive when the therapist, whose own self-esteem is dependent on the patient's progress in therapy, forces a "rush to recovery" on the patient; (c) other personal issues in the life of the therapist that may also resonate with experiences of the patient; (d) "countertransference goodness and availability" as it affects therapists' abilities to set reasonable limits on their patients, as well as reasonable expectations for themselves; and (e) special issues regarding therapist transparency and self-disclosure.     

Psychological Interpbetation by Leon H. Levy

Hispanics in the United States mainland underutilize mental health services and drop out of treatment sooner than dominant culture groups. One reason for this problem is that the sociocultural value orientation and expectations of the Hispanic patient are discordant with the values and expectations of the professional offering help. This paper focuses on the special problems resulting from the sociocultural differences between therapist and patient, and discusses why group therapy is uniquely suited to address these problems. It argues that group therapy offered by a leader with knowledge of the culture has an advantage over other forms of treatment in engaging Hispanic patients and in helping them to increase the effective use of mental health services. Issues of group formation, pregroup contracting, and the stages in the life of a Hispanic therapy group are also discussed.     

The contribution of feedback to outcome in long-term group psychotherapy

Two long-term analytic inpatient psychotherapy groups, comprised of severely disturbed neurotic and personality disordered patients, were intensively investigated using process ratings and therapist and patient reports to examine the contribution of interpersonal feedback to treatment outcome. We found that feedback was important throughout the course of therapy, and that patients who derived the most benefit from the groups were those who experienced a greater level of group cohesiveness and were most active in terms of self-disclosure, receipt of feedback, and making significant behavioral modifications within treatment. These successful patients received both positive and negative feedback, primarily from other group members, and worked effectively toward the goals that brought them to treatment.     

Employing the God-Family Relationship in Therapy with Religious Families

In many religious families, God functions as a crucial family member, stabilizing interpersonal relationships and engaging in daily family transactions. In the psychological role of a transitional object, God can be usefully employed by the family therapist in therapeutic interventions, when the therapist keeps the focus upon the interpersonal relationship with God rather than the specific content of religious beliefs. This approach can access a vital resource in the family, particularly when conditions for therapy are otherwise difficult, such as an isolated, enmeshed dyad presenting alone for therapy. Four case examples illustrate how one may use this approach in family therapy.     

Parting gifts: termination rituals in group therapy

A patient's termination from group therapy is a powerful experience for the departing patient, the therapist, and all group members. Unless the feelings evoked are channeled into constructive expression, they may undermine this potentially valuable phase of both the departing patient's group treatment and the life of the group as a whole. A termination ritual, styled by a particular patient according to his or her own need, therapy goals, and personality may help the patient achieve a more clearly defined sense of self. The authors suggest that the group therapist's careful attunement to and thorough exploration of the significance of any termination ritual or gift will help to extract maximum therapeutic benefit for the departing member and the group as a whole.     

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.     

The Jerusalem TeleRehabilitation System, a new low-cost, haptic rehabilitation approach.

Survivors of brain injury or stroke can improve movement ability with intensive, supervised practice. Since the hours of supervised therapy with a physical or occupational therapist are limited, telerehabilitation will enable patients to greatly expand the hours that they practice therapeutic exercises. The Jerusalem TeleRehabilitation System (JTRS) consists of patient and therapist systems plus a central server and database connected via the internet. The system can work in two modes: (1) a cooperative mode in which the therapist and patient are online at the same time, and (2) a stand-alone mode in which the patient uses the system on his own. In both cases, the system will monitor the status and progress of the patient and various parameters of his movement abilities, and prepare reports for the patient and for the therapist. From the clinic, the therapist will be able to change the screen seen by the patient and change the level and types of tasks, as needed. Compared to existing systems, our system will have the following advantages: (1) inexpensive and easy to use; (2) remote monitoring and control of the patient's computer by the therapist in the clinic; (3) more detailed analysis of patient status and progress; (4) a "smart" system which self-adapts to the patient's capabilities in real time, increasing or decreasing the difficulty of the exercise as needed; and (5) a central, international database which, by gathering data on many patients over time, will provide the basis for "smart" therapy and will also facilitate coordinated multicenter research studies.     

Treatment Engagement: Building Therapeutic Alliance in Home-Based Treatment with Adolescents and their Families

Client engagement is an essential yet challenging ingredient in effective therapy. Engaged clients are more likely to bond with therapists and counselors, endorse treatment goals, participate to a greater degree, remain in treatment longer, and report higher levels of satisfaction. This study explored the process of engaging high-risk youth and their parents in a unique home-based family therapy intervention. Qualitative interviews were conducted with 19 families who completed family therapy sessions that included a core component aimed at increasing treatment engagement. Parents’ and youths’ perceptions of engagement suggest the importance of developing therapeutic alliance with therapists, who facilitated building a shared alliance among family members. Implications for improving client engagement are discussed within the context of alliance building with the therapist and among family members.     

A systemic view of family therapy ethics

A critical review of the literature on family therapy ethics is used to develop the proposition that a more systemic analysis is needed, one that includes the levels of therapist and society as well as patient (family). These ideas are discussed through reexamining the issues of family secrets, therapist deceptiveness, and therapist advocacy of personal (feminist) values.     

Separation and loss in psychoanalytic therapy with borderline patients: Further remarks

This paper is a continuation of an earlier one concerning borderline patients, and I can recapitulate only a few of the many areas touched upon here. The borderline individual is faced continually with the threat of loss, either of his tenuously established individual identity, through fusion with the other person, or of his fragile interpersonal relatedness, through uncontrollable flight into autism of psychotic degree. A basic theme in one's work with these persons is that of unconscious, fantasied omnipotence, variously an aspect of the patient's unconscious self-image or projected into the therapist. The acting-out which the patient does consists in his inflicting loss, deprivation, and other forms of injury upon his introjects of part-aspects of the therapist. The grief involved in the relinquishment of so-called bad introjects is discussed. The patient early in therapy is aware of his inability to grieve, and endeavors to conceal this deficiency by spurious emotionality. I give examples of patients' manifesting regressive dedifferentiation to fusion with elements of the nonhuman environment, as an unconscious defense against feelings of separation and loss. Effective therapy with these patients involves the therapist's deeper working through of his own losses. The significant losses occurred so early in these patients' lives that the therapeutic exploration of these areas may enable the therapist to gain access to comparably early losses on his own part, losses from a developmental era which many a training analysis may not have explored at all adequately.     

The Anorectic Process in the Family: A Six-Stage Model as a Guide for Individual Therapy

This article presents a conceptual framework for individual treatment with chronic anorectic patients. In the first part of the article, the six-stage model for the anorectic process developed over the past years by M. Selvini-Palazzoli and her team is briefly explained. After presenting the model, we then discuss some related concepts, namely, "family game," "rule," and "strategy." Finally, the therapeutic technique in individual treatment is discussed. Two basic assumptions underlie this technique: first, the therapeutic relationship is instrumental, its main purpose being to improve the patient's personal relations outside therapy; second, the focus of the treatment is on the strategic incapacity of the patient who is caught up in and unable to cope with the "concealed family game."     

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.     

Spontaneous Personality Synthesis in Group 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 clarify 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.     

The use of children's drawings in multiple family group therapy

This paper describes the advantages, difficulties and techniques of including young children in multiple family group therapy (MFGT). Multiple family group therapy consists of weekly sessions where three or more families meet conjointly with a therapist or cotherapists. Clinical vignettes demonstrate how to use children's drawings with parents to improve family communication. The efficiency of MFGT is compared to family therapy or individual therapy. The effective use of this modality with some children under 10 years is discussed.This research was supported in part by Alcohol, Drug Abuse, and Mental Health Administration Psychiatry Education Branch Grant MH 13882 from the National Institute of Mental Health.     

‘The experiencing of experience’: a Pragmatic reassessment of Rogerian Phenomenology

This paper draws on a study that asked twenty family users about their first session of family therapy. Analyses of the interviews indicated that families entered therapy with a pre-existent knowledge about therapy, which did not always chime with those of professionals and which positioned speakers in ways which governed their expectations and perceptions of therapy. This paper, therefore, is concerned with the acquisition and deployment of knowledge: specifically, the knowledge involved in being a user of family therapy. Three key discourses were identified through this analysis: medical, counselling and consumerist. We aim to illustrate how these discourses served as a resource for members of the family in constructing therapists, therapy and themselves in relation to their experience. The examination of the rhetorical, ideological and practical effects of the positions chosen and the objects constructed, in terms of how speakers wanted to present themselves, with what enhanced or diminished status as patients, shows users actively engaging with the power of therapeutic institutions. Users’ accounts suggest that while most speakers felt anxious about the prospect of therapy, there were clear differences in overall satisfaction/dissatisfaction with the experience according to the synchrony between speakers’ construction of the therapist, and themselves as client/patients. Those who seemed to take a traditional view of therapy within a medical discourse valued therapists who offered diagnosis and a cure; those who sought and experienced a counselling relationship with the therapist found their experience to be constructive in terms of enhanced self-knowledge. We believe that the research findings discussed in this paper have implications for family therapists in accommodating to parental and child positions to maximise the effectiveness of therapy and so minimise drop-out.     

An experimental inquiry into transference roles and age

In this psychotherapy analogue investigation, the effects of client age and therapist age on transference-like projections onto therapists were examined. Young (25-35) and older (60-70) pseudoclients compared paraprofessional therapists to significant figures in their own lives after a dyadic "helping" interview. The results provide empirical support for the phenomenon of reverse transference in therapy with older patients. Older clients were more inclined than young clients to view therapists, particularly younger therapists, as similar to their children. Young clients more willingly attributed parental qualities to older therapists. Both old and young clients may see therapists more as peers or friends than as family members.     

Introduction to Group-Analytic Psychotherapy by S. H. Foulkes

This article will explore special leader issues that emerge in psychodynamically oriented therapy groups with adult children of alcoholics. Particular focus will be on countertransference feelings that get stirred up in group leaders and techniques for dealing with some of these special dilemmas. Specific issues include (a) assumption of sameness between the therapist and the patient (the therapist assuming that he or she “understands” because of having also grown up in an alcoholic family); (b) the “will to restore,” which may be destructive when the therapist, whose own self-esteem is dependent on the patient's progress in therapy, forces a “rush to recovery” on the patient; (c) other personal issues in the life of the therapist that may also resonate with experiences of the patient; (d) “countertransference goodness and availability” as it affects therapists' abilities to set reasonable limits on their patients, as well as reasonable expectations for themselves; and (e) special issues regarding therapist transparency and self-disclosure.     

When the therapist says goodbye

Therapist-initiated termination poses several unique problems for both the group and the therapist. This paper describes the termination process from the point of view of this therapist's experience in planning the termination of her group therapy practice. The reactions of other analysts to her decision to retire and the group processes and individual patient's reactions in this long-term psychoanalytic therapy group are described in detail. The author follows the group process and her own inner processes in the final six months of the group. The importance of the working through of the termination phase of therapy is supported by the experiences that were shared by the group and the therapist.     

Anxiety symptom focus in sessions of cognitive therapy for depression

The comorbid patient presents an especially difficult problem to a therapist who is attempting to implement a short-term, focused therapy. The current study investigates the effect of comorbid anxiety on cognitive therapy for depression. Participants were a subset of patients (N=24) assigned to the cognitive therapy arm of a large, randomized, controlled trial of treatment for depression. From intake assessments, patients were classified as having low or high levels of comorbid anxiety. Two videotapes of each patient's therapy sessions were coded. Irrespective of intake anxiety level, more time and effort spent addressing anxiety in session was found to predict less improvement in both depression and anxiety symptoms over the course of treatment.