Issues in psychotherapeutic encounters of patients suspected of post-traumatic stress disorder malingering

The literature indicates on high rates of post-traumatic stress disorder (PTSD) malingering in various mental health settings but only few articles relate to therapeutic encounters with this population. The aim of this article is to present some of the difficulties that characterize psychotherapeutic encounters with patients suspected of PTSD malingering, and to examine the vicissitudes of significant elements of psychotherapy during these complex clinical situations. Some therapeutic interventions and indications that may help therapists to distinguish between patients with exaggerated symptomatology who suffer from true mental distress, and from full malingerers are also provided. It is argued that therapists and policy makers should relate to PTSD malingering more seriously due to the negative consequences of this phenomenon.     

Time-limited counselling

Abstract

This paper introduces a new synthesis of approaches to time-limited psychodynamic counselling, giving an account of some of its antecedents and of some of the values which underlie therapeutic effectiveness.

It offers a discussion of the impetus which may be obtained by facilitating the client in working towards a positive outcome which is clearly identifiable. Two time-limited counsellings are then described, in which the underlying conflicts, surrounding loss in the first and impaired trust in the second, are seen to emerge. Finally, some ethical issues are raised and the effects of the planned ending on the client's unconscious process are described.

Mental health, in the humanistic sense, is characterized by the ability to love and to create, by the emergence from the incestuous ties to family and to nature, by a sense of identity based on one's experience of self as the subject and agent of one's powers, by the grasp of reality inside and outside of ourselves, that is by the development of objectivity and reason.     

“A Failure of Curiosity”

ABSTRACT

This essay discusses the clinician's defense against and resolution of the experience of boredom in the countertransference as an incident of projective identification in the treatment of a woman with dissociative identity disorder. The essay details the inner mind of the therapist as she discovers both her own feelings and judgements of those feelings. As the essay progresses, she begins to grasp the significance of her discomfort in informing the therapeutic process. We watch as this material is made use of to move forward a stalled therapy into new territory.     

Self-Disclosure and Vulnerability

Abstract

Based on the theoretical assumption and clinical observation that projective identification is a natural, constant element in human psychology, clinical material is used to illustrate how projective identification centered transference states create situations where acting out of the patient's phantasies and conflicts by both patient and therapist is both common and unavoidable. Because they are more obvious, some forms of projective identification encountered in clinical practice are easier for the analyst to notice and interpret. Other forms are more subtle and therefore difficult to figure out. Finally, some forms, whether subtle or obvious, seem to create a stronger pull on the analyst to blindly act out.

In some psychoanalytic treatments, one form of projective identification might embody the core transference. In other cases, the patient might shift or evolve from one level of this mechanism to another. Some patients attempt to permanently discharge their projective anxiety, phantasy, or conflict into the analyst. There is a patent resistance to re-own, examine, or recognize this projection. Some of these patients are narcissistic in functioning, others are borderline, and many attempt to find refuge behind a psychic barricade or retreat (Steiner 1993). In other forms of projective identification, the patient enlists the analyst to master their internal struggles for them. This occurs through the combination of interpersonal and intra-psychic object relational dynamics. This “do my dirty work for me” approach within the transference can evoke various degrees of counter-transference enactments and transference/counter-transference acting out.

Another form of projective identification, common in the clinical setting, is when a patient wants to expand the way of relating internally, but is convinced the analyst needs to validate or coach the patient along. This is why such a patient may stimulate transference/counter-transference tests and conduct practice runs of new object relational phantasies within the therapeutic relationship. Over and over, the patient may gently engage the analyst in a test, to see if it is ok to change their core view of reality. Depending on how the analyst reacts or interprets, the patient may feel encouraged to or discouraged from continuing the new method of relating to self and object. The patient's view of the analyst's reactions is, of course, distorted by transference phantasies, so the analyst must be careful to investigate the patient's reasoning and feelings about the so-called encouragement or discouragement. This does not negate the possible counter-transference by the analyst in which he or she may indeed be seduced into becoming a discouraging or encouraging parental figure who actually voices suggestions and judgment.

All these forms of projective identification surface with patients across the diagnostic spectrum, from higher functioning depressive persons to those who are more disturbed paranoid-schizoid cases. Whether immediately obvious or more submerged in the therapeutic relationship, projective identification almost always leads to some degree of acting out on the part of the analyst. Therefore, it is critical to monitor or use the analyst's counter-transference as a map towards understanding the patient's phantasies and conflicts that push them to engage in a particular form of projective identification.     

Centered Selves Connecting with Each Other

SUMMARY

Featured is an excerpt from an edited, transcribed lecture presented August 1987 at Avanta Process Community VII in Crested Butte, Colorado. The lecture was part of a month-long seminar which also included demonstrations and exercises. The lecture includes preparing therapists for the first session with patients for maximum therapeutic advantage.     

Pursuit of Bodily Excellence: Paul Weiss’s Platonic (Religious) Imagination of Sports

Almost thirty years ago, Warren Fraleigh wrote that Paul Weiss’s intellectual contribution to the philosophic study of sport was like a tributary, converging with others to eventuate in numerous scholarly colloquia, a new academic society, new courses and curricula, articles and books. Paul Weiss contends in Sport: A Philosophic Inquiry that sport is a pursuit of bodily excellence. Weiss tells a story about bodily excellence; it is a bodily good that can be realized in the practice of sport. His metaphysic and teleology provide the content and context for his philosophy of sport. For him, sport bodies speak or give voice to a particular metaphysical tradition that I argue is problematic. Weiss’s metaphysic and teleology swallow and sublate sportive bodies and the concomitant goods intrinsic to embodiment and the practice of sports. The net effect is dematerialization and depersonalization of bodily performances and personal identity, respectively. More recently, Feezell and Dombrowski advance theses about sports with Weiss as their primary interlocutor, if not foil. What I put forth travels a different path than Dombrowski and Feezell in that I plumb Weiss’s narrative arc, Platonic imagination and metaphysic, more extensively as it tells a certain story about human embodiment, and thus, grounds his ideal of excellence.     

Is three a crowd? A perspective on countertransference challenges in psychoanalytic couple psychotherapy

Two seemingly unrelated characteristics of psychoanalytic couple psychotherapy may be better understood when juxtaposed. First, countertransference in psychoanalytic couple psychotherapy holds particularly strong intensity. Second, format decisions are central to couple psychotherapy. The use of conjoint and concurrent formats, or variations thereof, has been key in the historical development of couple psychotherapy and remains an area of much debate. Some couple psychotherapists use the format of couple psychotherapy flexibly, using variations of conjoint or concurrent couple psychotherapy, while others adhere strictly to working conjointly. Decisions regarding whether to undertake concurrent or conjoint therapy are not generally linked to countertransference; this article demonstrates that reading decisions regarding format through consideration of countertransference offers a needed perspective for the therapist. Case studies published by psychoanalytic couple therapists are analysed through this prism to demonstrate that changing the format may serve to dilute countertransference. One particular manifestation of countertransference, linked to oedipal dynamics, is explored: countertransferential intensity for couple psychotherapists potentially relates to being faced with their internal parental couple and their unresolved Oedipal strivings. Possible unconscious motivations to change the format of couple psychotherapy need to be carefully considered, as format changes may mask an avoidance of bearing the countertransference.     

‘Feeling for’ and ‘feeling with’: developmental and neuroscientific perspectives on intersubjectivity and empathy

This paper discusses research by Beatrice Beebe, Bessel van der Kolk and others, exploring the interpersonal processes that underpin early relational trauma and how this contributes to adult psychopathology. An essential feature of early relational trauma, the infant's experience of being unable to evoke an empathic response from the caregiver and the feelings of shame this gives rise to, is discussed and its implications for psychotherapy are considered. The neuroscience that underpins two forms of empathy in the therapeutic relationship, of ‘feeling for’ and ‘feeling with’ the patient is discussed and explored in relation to the concordant and complementary countertransference. I argue that when therapists respond to the projection on to them of the abuser by an increasingly determined adherence to analytic technique, this may become a complementary countertransference identification with the abuser and an enactment of the abusive relationship.     

Impervious and intrusive: The impenetrable object in transference and countertransference

The author describes an internal object that he calls the ‘impenetrable object’ which has two characteristics: being impervious to the projections from the patient and being intrusive, i.e. projecting into the patient. It arises out of an early relationship with a mother who may be generally disturbed or traumatized so that she is unable to take in or tolerate the child's projections and may use the child as a receptacle for her own projections. He links the concept of an impenetrable object with other concepts such as Williams's ‘reversal of the container–contained relationship’ and Green's ‘dead mother’. If such an object dominates the patient's internal world, it can lead to severe difficulties in the analytic process. Interpretations may be experienced as violent projections from the analyst which the patient has to ward off and the analyst may enact an impervious or intrusive object in various ways. The author describes a case in which such dynamics played a significant role. He argues that intensive work in the countertransference is required to detect subtle enactments and allow a shift in the analyst, which in turn can enable change in the patient. He gives clinical material that demonstrates such work by the analyst and illustrates the shift from an impenetrable object to a more permeable one in the patient's internal world.     

Silent dialogues in the analytic relationship

Abstract

In borderline or even narcissistic patients, the relation to the objects is built on the basis of omnipotent control, so that those patients present difficulties related to mourning for the loss, as well as for the independence, of the objects. Their basic trait is a huge inability to recognize the separateness of others, together with an excessive use of primitive defense mechanisms, such as projective identification. Each experience that contains the danger of re-experiencing the primal separation poses an attack on the analytic setting, in order to avoid such a re-experiencing. Those attacks sometimes take the known form of acting out, whereas other times they are limited to a special use of speech, which lacks any communicational faculty and is used rather as a weapon. This special climate affects the analyst, causing specific countertransferential reactions. Nowadays, we tend to consider such a communication not mostly as an obstacle, but rather as an opportunity, allowing the analyst to comprehend the patient, through his countertransference, and create a meaning to replace the void those patients usually experience. The transference and countertransference enactments, their silent dialogues taking place in the analytic setting, are those which progressively give meaning in this primitive non verbal communication.