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PubMed1994

Psychological interventions for the suicidal adolescent.

Acute and chronic styles of suicidal behaviors require different psychotherapeutic approaches--the former needs a supportive-cognitive-focused approach, the latter (chronic or characterological) style needs an expressive insight-oriented psychotherapy with supportive elements to address the adolescent's developmental requirements for structure within the sessions. The psychotherapist needs to be appraised of the epidemiological, dynamic factors as well as the sources of external support the patient can count upon. It is interesting to note that psychodynamic factors alone or psychopathology alone are not sufficient to estimate the ebb and flow of the suicidal risk. A combination of all these factors must be taken into account in estimating suicidal risk at any point in treatment. It is advisable that an independent clinician's consultation be sought during treatment in the case of suicidal attempts as the therapist can easily overestimate or underestimate suicidal risks. Individual treatment requires family intervention from counseling to therapy. Particular problems addressed in the paper are countertransference reactions created by the suicidal behavior in the clinician such as rejection and withdrawal. The psychotherapy should address the resolution of aggressive, envious introjected images, issues of omnipotent control and interpersonal skills deficits. To transform suicidal behavior into reenactment of the aggression within the relationship to the therapist is the main immediate goal. A critical caveat; a patient who lies by commission or omission represents an obstacle for individual therapy on an outpatient basis as he will disguise his suicidal intentions and plans, excluding them from the therapeutic process.

Adolescent↗
PubMed1994

Depression and denial in psychotherapy of persons with disabilities.

Disability may challenge some basic assumptions about the world, and some psychological aspects of self may be profoundly violated, particularly when onset is sudden and functional changes seem catastrophic. The losses incurred in disability, broadly defined, whether minimal or major, physical, psychologic, symbolic, or all of the above, may lead to some predictable human emotional responses, although individual patients' responses do vary. Factors including prior life history, concurrent life stressors, social and financial resources, intrapsychic functions, psychodynamic issues, and personal/subcultural issues may influence the experience of disability. Depression, as a natural concomitant to loss, may present in clinical form or in bereavement and grief patterns, and warrants full consideration (both diagnostically and therapeutically). In treating the patient with a disabling loss, the dynamic nature of denial must also be considered. The often visible inability or disability may stand in sharp contrast to that which is denied. The risk/benefit ratio of denial is a consideration when the psychotherapist weighs the need to maintain denial defensively versus the advisability of confronting the denial in an attempt to soften its brittleness. Countertransference reactions are also of prime importance and may differ from more typical reactions by virtue of the enormity of the patient's losses and their tendency to evoke the psychotherapist's own sense of vulnerability, mortality, and humanity.

Adaptation, Psychological↗
PubMed1994

Psychotherapeutic issues with family members of persons with physical disabilities.

The need for individual psychotherapy for family members of persons with physical disabilities is growing as medical interventions improve and survival rates increase. The family members' grief reactions are one part of the adjustment process. Psychological difficulties that develop are influenced by a number of considerations. The family member as psychotherapy patient is part of a family unit whose balance, functioning and development has been disrupted. Factors relevant to physical disability, family systems approaches, and psychodynamic theory are influential in the treatment. The extent and type of a relative's disability determines the practical and personal impact for the patient as does the relationship of the patient to the person with the disability. A spouse, parent, child or sibling will each experience different practical and emotional consequences within the context of his/her ages, stage of life, and culture. The circumstances of the onset of the disability, the quality of the relationship, and the psychodynamic balance within each person and within the relationship are important issues to consider. All of the above affect the meaning of the disability for each family member personally, interpersonally, intrapsychically, and within the family unit. Because of limited experience with these emotionally loaded issues, possibilities for countertransference are significant. Recommendation is made for increased exposure to the area of physical disability in the training of psychotherapists.

Adaptation, Psychological↗
PubMed1994

Object relations theory and pharmacopsychotherapy of anxiety disorders.

This paper provides an overview of object relations concepts, applying them specifically to combined psychoterapy-pharmacotherapy of anxiety disorders. Anxiety in this clinical theory is conceptualized as arising from threatened loss of the self- and object-relationship. At a rudimentary level, individuals can attempt to manage potential loss through splitting and projective identification. As benign and loving experiences accumulate and ego functions neurophysiologically develop, whole object relations provide alternate and more modulated ways of coping with anxiety. In anxiety disorders, these more mature coping styles break down. Treatment combining object relations approaches to psychotherapy with pharmacotherapy pay particular attention to the relationship aspects and meanings of medication and prescribing. These approaches use the concepts of empathy, containment, countertransference, splitting, projective identification, and transitional object formation to help patients come to terms with their anxiety and with the treatment relationship.

Adult↗
PubMed1994

Supportive psychotherapy of the schizophrenic patient.

The unimpressive results, in several classic studies, of expressive psychotherapy for schizophrenic patients have led to a neglect of all dynamic psychotherapy for these patients. However, there have been significant advances in psychodynamic supportive therapy over the past two decades and currently it is both well grounded in psychodynamic theory and has an accepted set of strategies and techniques. In this paper, we apply the general principles of psychodynamically oriented supportive therapy to the outpatient treatment of the schizophrenic patient. Outpatient treatment is divided into stabilization and maintenance phases. During stabilization, treatment focuses on building a therapeutic alliance, psychoeducation (including the family where appropriate) and establishing a bilaterally acceptable, clinically effective, pharmacological regimen. In the maintenance phase, the therapist becomes more therapeutically ambitious, particularly in undermining maladaptive, and supporting adaptive, defenses. Handling of the alliance, transference, countertransference, resistance, working through and attenuation (instead of termination) are addressed and illustrated with clinical material. The role of the supportive therapist also includes overall executive responsibility for the entire treatment, management of psychopharmacology, and clinically appropriate referrals for family work, social skills training and vocational rehabilitation. Studies are needed to determine the effectiveness of this treatment approach; further, whether it is applicable to all schizophrenic patients or only to a particular subgroup.

Adult↗
PubMed1995

The "erotic transference": some technical and countertransferential difficulties.

This paper highlights dynamics that may interfere with the therapist's identifying and addressing the erotic transference: (1) deficient training; (2) theoretical orientations that devalue the transference while espousing a "real" relationship including self-disclosure; (3) countertransference responses to the erotic transference; and (4) clinical errors of focusing on the manifest erotic transference while overlooking significant but latent pre-oedipal, oedipal, aggressive, or selfobject issues. Inattention to these dynamics may render the therapist vulnerable to sexual acting out with his patient.

Adult↗
PubMed1996

Collusion and entanglement in the therapy of a patient with multiple personalities.

S.'s therapy demonstrates some of the ways in which countertransference interferes with therapy of a case presenting with multiple personalities. Fascination with S.'s alter personalities and the desire to prove their genuineness, made her therapist search for them and then repeatedly invoke their appearance. Part of the reason was his inexperience with such cases that induced him to "play it by the book," and use "personality-centered procedures" (looking for a different part, giving it a name, speaking to it, etc.) that have yet to be scientifically validated, instead of adhering to the basic principles of psychotherapy. At a deeper level, however, his excessive preoccupation with S.'s personalities was one kind of collusion with her resistance to deal with the focal issue of her sexual ambivalence. Proof of this resistance also surfaced later as a motivated shift of focus in therapy, and a weakening of the therapeutic alliance. By the time this was evident, sabotage of therapy had already occurred.

Adult↗
PubMed1996

Lessons to be learned from the study of sexual boundary violations.

The study of sexual boundary violations, through the actual evaluation and treatment of therapists who have engaged in sexual misconduct, reveals that all of us are potentially vulnerable to violations of this nature. A number of lessons can be learned from the detailed examination of these cases. These lessons include the following: (1) There is a difference between the conscious and unconscious intent of the therapist. (2) "Love" in the therapeutic setting is fraught with problems, including the fact that it is often used as a defense against the therapist's own aggression. (3) Supportive therapy and boundaryless therapy often become confused when a therapist switches from an expressive to a supportive approach. (4) The thoughts, feelings, and behaviors that a therapist would most like to keep secret from a supervisor or consultant are the most important issues to discuss with that supervisor or consultant. These observations have a number of implications for prevention. Matters of technique are inevitably conflated with issues of ethical principles so that the teaching of ethics must include discussions of transference, countertransference, and the use of third parties, such as supervisors or consultants, to assist the therapist in the monitoring of professional boundaries.

Countertransference↗
PubMed1996

Our time is up: forced terminations during psychotherapy training.

Forced terminations are a powerful experience for both patients and for residents. Such terminations often resemble earlier losses to patients, who may react with particular defense constellations, changes in symptoms, and profound reactions to the therapist. Similarly, prominent countertransference may manifest in attempts by residents to deny their importance to patients, to project reactions onto their patients, and to alter the therapy relationship. More intense therapy relationships usually require termination announcements months in advance. How much will be revealed to patients may best be determined prior to the announcement. Payments, gifts, subsequent contact, transfer to another therapist, and concluding therapy comments need evaluation of what is in the patient's best interest and may require creative approaches deviating from traditional therapy practices. This discussion reviewed reactions of patients and residents to forced termination, addressed the pragmatic issues confronting the resident, provided clinical vignettes illustrating peculiarities of forced terminations, and listed recommendations to assist the departing resident. Forced terminations afford powerful opportunities for contending with abandonment, disappointment, and loss directly in the therapy. While these experiences are certainly not comfortable, they can be used constructively to benefit patients if the issues surrounding the forced termination are carefully considered and addressed within the therapy.

Adult↗
PubMed1997

Object relations couple therapy.

The authors describe Fairbairn's view of the personality as a system of parts of self and object in dynamic relation, formed in the context of dependent early relationships and replayed in the intensely intimate and physical relationship of marriage. Through Klein's concept of projective identification, a spouse finds lost parts of the self in the partner, where they may flourish and be reintegrated into the self or they may be held hostage. Marriage is an opportunity for reworking the dynamic relation of parts of the self as they are modified through mutual unconscious interaction with the spouse, but it may become a closed system that inhibits growth of the individual partners. Object relations couple therapy aims to breach the closed system of the unhappy marriage, and offers an enlarged space for understanding that encourages the spouses to provide a better holding environment for each other. Not directive, didactic or symptom-focused, object relations therapy values affect, silence, body language, fantasy, dreams, and transference phenomena as necessary for reaching the unconscious in order to achieve insight. The object relations therapist interprets defenses against anxieties that underlie repetitive patterns of unhelpful behavior, and works toward understanding. As the clinical vignettes show, therapists use countertransference to understand the couple's shared transference from inside their experience. The engine of therapeutic change in this model is the therapist's self. The process of therapy improves the couple's capacity for containing each other's projections instead of refusing to resonate with them or being overtaken by them to the detriment of the self. A cycle of regression and progression in the couple's ability for containment is found as therapy proceeds. The goal of therapy is to enable the projective and introjective identificatory system of the marriage to function with greater concern for the other and respect for the self.

Adult↗
PubMed1997

Healing the incest wound: a treatment update with attention to recovered-memory issues.

This article provides an updated treatment model for adults who report having experienced incestuous abuse in childhood. It integrates psychodynamic, traumatic stress, developmental and feminist formulations, accords greater emphasis to object relations and self-psychology perspectives, includes more attention to dissociative reactions, and utilizes more cognitive-behavioral interventions. It is also responsive to issues raised in the recovered/false memory controversy. This holistic model is sequenced, paced, and titrated according to the patient's characterological structure, ego strength, and needs as well as the range and severity of presenting problems and life difficulties. Special consideration is given to issues pertaining to memory and the maintenance of a neutral stance by the therapist, especially in the case of recovered rather than continuous memories and/or suspicions rather than actual knowledge of abuse. Contemporary perspectives regarding some of the unique transference, countertransference, and vicarious traumatization issues with this population and their potential impact on treatment are also discussed.

Adolescent↗
PubMed1998

Self-mutilation, substance abuse, and the psychoanalytic approach: four cases.

While self-injury and substance abuse are difficult symptoms for both analyst and patient to cope with, and relapses are frequent, the emphasis does not have to be on managing crisis. The initial ego support and therapeutic boundary setting in these difficult cases must be matched by psychoanalytic exploration. In working with these patients, I find that, through mutual projective identification processes, the analyst and the patient are frequently resurrecting certain aspects of the patient's archaic phantasy life as defined by various self and object representations. Therefore, the continuous analysis of the transference and the countertransference is certainly essential. However, the additional willingness on the part of the analyst and the patient to explore the frequent and mutual interpersonal/intrapsychic acting out is paramount.

Adult↗
PubMed1998

Engaging in psychotherapy with the Orthodox Jew: a critical review.

A critical overview of the current knowledge of engaging in psychotherapy with a cultural minority, Orthodox Jews, is provided. The various forms of psychotherapy that have been utilized to engage Orthodox Jews in meaningful psychotherapeutic encounters are discussed. Psychodynamic, cognitive, behavioral, couple, family, and group therapies have all been employed with success. The first key in working with cultural minorities, including Orthodox Jews, is patience. Patience is required to allow a therapeutic alliance to develop in which the therapist, the outsider, can be trusted. When patients are reluctant to accept the treatment proposed, patience is necessary to give them the time required to verify the treatment with someone they trust, often their rabbi in the case of the Orthodox Jew. Patience is also valuable when patients request a change in the frame of therapy, such as the use of a chaperon or leaving the door slightly ajar if being treated by a member of the opposite sex. The second key in working with this or any other cultural minority is flexibility. Flexibility is required, to chose treatment modalities that best fit with the patient's beliefs, to respect the patient's beliefs no matter the extent they deviate from the therapist's own, and finally, to be critical of oneself when examining transference and countertransference reactions.

Countertransference↗
PubMed1999

Assessment of suitability for psychotherapy. II. Assessment based on basic process goals.

Part II of this paper presents an outline for the assessment of suitability for psychotherapy based on the patient's ability to participate in the basic tasks of the therapeutic process and provides a coherent approach to this complex and difficult task. Several factors, such as therapeutic interaction and relational history, influencing the patient's ability to form a productive working relationship can be assessed clinically and are well supported by research. Others, such as motivation and supportive life circumstances, although less supported by research, still appear to be clinically important. Influences on the ability to create a model of the patient's psychopathology, such as introspection, circumscribed focus, and some aspects of the model itself, are supported by limited research but important for some therapies. There is little research on trial interventions, though these remain a crucial assessment dimension for short-term therapies, particularly. Countertransference, although traditionally not viewed as part of assessment, is actually an important tool that has been validated by research.

Countertransference↗
PubMed1999

Interpreting transference in the supervision of psychoanalytic psychotherapy.

Supervisors of analytic psychotherapy have long wrestled with the question of whether interpretation has a legitimate role in dealing with supervisee countertransference and the transferences of the supervisory experience, itself. Currently, the majority view relies on didactic methods to deal with these transferences and avoids interpretation as incompatible with, even dangerous to, the supervisory task. This paper takes issue with this view and uses a clinical example to illustrate the impact and irreplaceable value of direct interpretation in supervision. It demonstrates that interpretation of a resistance in the supervisee can fundamentally and beneficially affect the therapeutic relationship, the supervisory process, and can have unanticipated diagnostic significance. It also demonstrates that, when applied with the same appropriateness and tact taken for granted in psychotherapy, concerns that supervisory interpretation will be traumatizing or counterproductive are unwarranted.

Adult↗
PubMed2000

Object relations and intersubjectivity in depression.

Starting with a clinical vignette the authors discuss Freud's thesis from "Mourning and Melancholia" (1917) that depression is a defense against the experience of loss: Whilst a part of the self remains identified with the lost object another part directs all the aggression against it that originally had been directed against the object. As a result the relationship between self and object becomes replaced by a pathological relationship between parts of the self. As psychoanalytical and phenomenological-hermeneutical approaches congruently show, one reason why mourning cannot proceed and feelings of guilt cannot be worked through lies in the fact that depressive patients need a symbiotic, idealizing type of identification with their objects in order to stabilize their identity. Because of their narcissistic vulnerability changes, personal failures, and disappointment by their objects, which may provoke unconscious aggression and fear of loss, can easily threaten their psychic equilibrium. This gives rise to considerable difficulties within the transference-countertransference relationship. The authors argue that to establish a feeling of autonomy in depressive patients, a secure framework within therapy has to be offered and at the same time the negative transference must thoroughly be worked through.

Adult↗
PubMed2002

Working with HIV/AIDS sufferers: "when good enough is not enough".

The authors begin by examining the intrapsychic implications that HIV/AIDS presents after knowledge of infection. Using examples drawn from two cases, they explore how knowledge of infection precipitates an insidious traumatizing process that comprises a number of key defensive strategies and dynamic processes. Particular kinds of defensive splitting, projective dynamics, and key identifications, as well as the collapse of the symbolic function, are isolated as being central to understanding the traumatizing process. With this in mind, the role and aim of the insight-oriented therapist is considered. The authors argue that much of the therapeutic work in this area revolves around a central organizing fantasy about the limitations of "good enough" objects in helping them with their diagnosis and its implications. This is linked to a number of technical dilemmas that the therapist will inevitability have to face if he or she chooses to work analytically. Particular technical problems explored include: 1. the management of frame deviations, 2. the therapist's role/s, 3. the use of interpretation, and 4. countertransference experience and enactment.

Acquired Immunodeficiency Syndrome↗
PubMed2005

In defense of listening.

This paper makes a case for listening and its role in establishing and maintaining meaningful psychotherapeutic relationships. Further, it examines those factors that have contributed to the devaluation and current decline of listening in mental health care. These factors include the abuses of managed care, the marketing and misuse of psychotropic medications, the growth of brief, manualized, empirically supported treatments (ESTs), and the lack of appreciation for unconscious processes and countertransference in the appeal, development and delivery of these interventions.

Countertransference↗