Anger - the hidden destroyer A psychodynamic approach with the physically disabled

Abstract

A basic challenge in the psychodynamic counselling of the physically disabled is the engagement of anger in relation to the patient's disability. Regardless of a patient's age at the onset of disability, they will exhibit anger, resentment and frustration for losses they may have, or perceive themselves to have, endured. Healthy physical and psychological adaptation requires the disabled patient to ‘cope’ with their anger. Feelings of anger may impede, obstruct or even derail the impetus towards healthy psychological and behavioural functioning. The manner in which we learn to negotiate the vicissitudes of daily life is linked to our selfobject development. This development does not end when we become adolescents or young adults, but continues throughout our life span. The normative, healthy psychological maturation required for adaptive behaviour is vulnerable to a wide range of impediments acquired at any point along the individual's developmental continuum. As clinicians we need to keep in mind that the self-regulation of internalized emotional states is transacted through a complex set of characterological and personality traits that may be impaired, or wanting, eventually leading to maladjusted psychopathological states. The therapeutic function of the clinician is to redress those ego deficits that stand in the way of a fully creative and productive life. The intended aim of this paper is to illustrate the manner in which I engage with those physically disabled persons presenting anger. I shall consider the use of counter-transference responses as behavioural in modifying various forms of anger formation manifested by disabled clients. It is my position that a positive shift in a disabled person's ego ideal through empathic transference will help to alleviate their underlying hostility and other forms of anger. The paper commences with a brief review of the experience of the disabled in Western society. I shall then turn to an examination of the psychotherapeutic approach underpinning my work with disabled clients. The third section will describe and illustrate, through case material, the clinician's use of self in the dyadic transaction with disabled clients.

The power of a positive therapeutic outcome lies in the clinician's ability to engage with the client despite emotional content, clinical aptitude or specific approach. Empathic attunement brings into operation those mechanisms underpinning the dynamic process integral to the approach used in the above cases. Countertransference issues sometimes intervene in the unconstrained flow of therapy. Regardless, those issues that are salient to the client and are incorrectly handled by the clinician will appear recurrently until satisfactorily addressed. Further, even when errors are made in sessions, outcomes may be positive.

Whatever the initial purpose that brings a physically disabled person to therapy there will eventually be a need to address issues around their condition. It is not enough to ignore or accept a client's earliest statement that their disability Ms not a problem'. They may initially not have come into therapy for problems concerning their disability; however, the particular disability will ultimately play an important role as to how and what the person feels, thinks and believes about him or herself. In general, psychodynamic counselling with the physically disabled requires knowledge of disability issues as well as of counselling procedures. Those working with the disabled need to understand their own personal issues through analytic work and continued supervision. Working with the physically disabled can be overwhelming, frustrating and exhausting, but in the end is most rewarding.     

Chapter 9 Clinical Risk and Brief Psychodynamic Therapy

Abstract

This article explores the risk environment confronting practitioners of brief psychodynamic treatment, and describes strategies that can help clinicians practice effective risk management. I argue that clinicians can reap only limited benefits from a focus on profiles of high-risk clients and litigation “hot spots.” The optimal approach is attention to the contextual dynamics shaping clinical practice. Among the most important are the relational processes driving the clinician-client dyad, the clinician-client-third party payer triangle, and the interface between the mental health and legal systems. I close with a discussion of the ambiguity and uncertainty that characterize clinical decision making and risk management.     

Chapter 2 Using Self Psychology in Brief Psychotherapy

Abstract

This article seeks to help clinicians make the translation from theory to practice when using self psychology to do brief psychotherapy. After a theoretical overview and review of the literature, a series of organizing questions and frameworks is provided to facilitate the clinician's capacity to apply a self psychological point of view to the understanding and conduct of brief treatment.     

Psychoanalysis and Personal Construct Theory: An Exploration

The similarities between two broadscale theoretical positions in psychology are discussed. Psychoanalysis is considered in terms of the new interpretation offered in the French rereading of Freud, and this reinterpretation is shown to be particularly relevant to the alignment of psychoanalysis with an already not too significantly different personal construct psychology.     

Does Depression Affect Clinical Practice?

Abstract

While recent autobiographical accounts of women psychotherapists with depressive illnesses have provided vivid and compelling portraits of therapists' experiences in therapy (e.g., Jamison, 1995; Manning, 1995), further research is needed to clarify the impact that depression and its treatment have upon both collegial relationships and clinical practice. A subset of the membership of the Association for Women in Psychology (AWP) was surveyed concerning therapists' experiences with depression and its treatment. Of 220 respondents, 76% reported some form of depressive illness. Eighty-five percent of respondents indicated that they participated in personal therapy. When evaluating their clinical work, respondents reported both positive and negative consequences resulting from their depression. While some respondents noted improvement in collegial relationships, many felt judged and avoided.     

Negative Treatment Effects in Dyadic Psychotherapy: A Focus on Prevention and Intervention Strategies

Therapy holds the potential to harm as well as help. This paper highlights approaches that may help prevent or decrease the incidence of negative effects in psychotherapy. These approaches include supervision, peer consultation, ongoing assessment of the therapeutic process, therapist-client matching, and referrals and transfers. We hope that this paper will serve as a stimulus for clinicians, psychotherapy researchers, and educators to put forth collabo-rative effort into identifying variables directly associated with adverse treat- ment outcomes and determining appropriate prevention and intervention strategies.     

Systematic Changes in Families Following Prevention Trials

A selective prevention design was applied to 238 recently separated families. Of these, 153 mothers randomly assigned to the experimental (E) group participated in 14 group sessions focused on Parent Management Treatment (PMT). Prior analyses showed that, over time, the group of families in the untreated group deteriorated in both parenting practices and in child outcomes. In keeping with the classic prevention pattern, families in the E group showed modest improvements in parenting and in child outcomes. Improvements in parenting were associated with significant reductions in problem behavior. The data showed that those mothers who improved their parenting skills during the first 12 months also showed significant reductions in maternal depression during that same interval. A cross-lagged panel analysis showed that a reduction in maternal depression during the first year of the study was a significant predictor of maintenance or improvements over the next 18 months. The findings are consistent with the concept of the family as a system.     

The effects of varying levels of treatment integrity on child compliance during treatment with a three-step prompting procedure

The effects of three levels of treatment integrity (100%, 50%, and 0%) on child compliance were evaluated in the context of the implementation of a three-step prompting procedure. Two typically developing preschool children participated in the study. After baseline data on compliance to one of three common demands were collected, a therapist implemented the three-step prompting procedure at three different integrity levels. One integrity level was associated with each demand. The effects of the integrity levels were examined using multielement designs. The results indicate that compliance varied according to the level of treatment integrity that was in place.