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PubMed1991

Simultaneous pregnancy in the therapist and the patient.

This report described the insight-oriented psychotherapy while both the therapist and patient were pregnant. The patient's pregnancy was not considered a consequence of acting out. With the growing number of female therapists, this issue will become more commonplace. The issues of dependency and traditionally feminine sex roles were initially found in Lisa's therapy and had been a focus for several months. However, her pregnancy catalyzed working through femininity issues and the therapist's pregnancy served to catalyze both issues. Pregnancy in the therapist is a template for dependency, abandonment, and sexuality issues. If the patient is a woman, role-model and identification issues are even more of a concern. In the patient, pregnancy serves to enhance the therapy because direction is already turned inward and there is even further self-absorption. If both the therapist and patient are pregnant, intense transference and countertransference are likely, and the skillful use of these will further the outcome of the therapy.

Adult↗
PubMed1992

Adding medications to ongoing psychotherapy: indications and pitfalls.

Research suggests that psychotherapy and psychopharmacology together have benefits beyond those when either is used alone. However, since many patients benefit from psychotherapy alone, medications are not always necessary. Medications should be added when patients are unable to deal with their problems in psychotherapy and their symptoms become troublesome. Drastic clinical deterioration, or increased anxiety or acting out that disrupts ongoing psychotherapy, are other indications. Patients' transference color their attitude towards prescribing, or not prescribing, medications and should be dealt with openly. Some patients equate their being given medications with caring, nurturance, or validation of their suffering. Others see it as an imposition of external controls, or a comment on their psychological weakness. Not being given medications benefits patients who think that the therapist "must be interested in me and not just in my symptoms" or that "I can do it myself." Angry, dependent patients may perceive it as withholding of support, prolongation of agony, not being taken seriously, or not being seen as sick enough. Therapists' countertransference may dictate the addition of medications as a distancing or even punishing maneuver. When prescribing, clinicians should choose specific agents with the least side effects, foster "psychopharmacotherapeutic alliances" to enhance compliance, and educate patients regarding common and serious--but not all possible--side effects to decrease complaints. Psychotherapy requires substantial skill to perform competently; psychotherapy and medication requires even greater sensitivity and does not mean that only half the usual attention can be paid to each modality.

Combined Modality Therapy↗
PubMed1992

Merging and emerging realities: simultaneous treatment of parent and child.

The purpose of this paper is to invite dialogue concerning the variety of modalities possible in the spectrum of child treatment. Many issues remain to be discussed, such as the child's need to possess the therapist entirely, and the role of other family members. Countertransference issues for the therapist are complex and involve the risk of dual loyalties. Simultaneous treatment shares these concerns with other modalities in the spectrum of child treatment. In simultaneous treatment, as parent and child come to share an experience of being cared for, the possibility arises for the dissolution of polarities. Representations of the past give way to adaptations to current reality. Both the parent's and the child's feelings of rage are contained within the therapeutic matrix of relationships; boundaries are maintained to permit repair and growth. Both parent and child reach new levels of integration as the therapist reinforces boundaries and does not permit intrusion by either the parent or the child into the others arena of playful construction.

Adult↗
PubMed1992

Obstacles to the dynamic understanding of therapist-patient sexual relations.

Several dynamic resistances appear to interfere with rational and empirically based discourse about therapist-patient sexual misconduct. These resistances include the lure of reductionism and a longing for simplicity; wishes for "political correctness"; gender bias; and confusion about the nature of the trauma in sexual misconduct. We conclude that (1) empirical study may produce unpleasant results; (2) "politically incorrect" models of misconduct merit study with care equal to "politically correct" ones; and (3) those reenactments we call transference-countertransference should be viewed in all their human complexity. Only then will our increased understanding of misconduct offer hope of prevention.

Ethics, Professional↗
PubMed1992

The prevention of psychotherapist sexual misconduct: avoiding the slippery slope.

Therapist sexual misconduct has its genesis in the therapeutic relationship. The mental health professions have long recognized the delicacy with which the therapist must handle the therapeutic relationship, with its power imbalance, inherent vulnerability of the patient, and transference and countertransference reactions. The prevention of sexual contact starts with the careful attention to boundary violations, which, though themselves perhaps not harmful, may escalate into sexualized behavior. Methods of preventing this behavior include the establishment of clear guidelines for practitioners and the expansion of the educational process for therapists, therapists' employers, patients, and other professionals. Last resorts lie in the legal and quasi-legal proceedings available to victims, such as civil suits for damages, criminal complaints, board of licensing complaints, and actions before professional associations. The best method of preventing sexual contact with patients involves respecting the boundaries of the professional relationship and avoidance of the slippery slope.

Ethics, Professional↗
PubMed1993

Basic principles of psychotherapy. I. Introduction, basic goals, and the therapeutic relationship.

This paper (Part I) outlines some fundamental principles of psychotherapy. The concept of "supportive" psychotherapy and the problems associated with those techniques are discussed, along with the advantage of learning basic principles of psychotherapy. The basic principles of psychotherapy are introduced in terms of basic goals. The techniques used in achieving the goal of an effective therapeutic relationship are discussed in detail. Other goals of creating an individualized patient model, making interventions, and monitoring countertransference are introduced but detailed discussion is left for Part II.

Adult↗
PubMed1996

Values in psychotherapy.

There is a tension between those who hold that psychotherapy is a scientific discipline and therefore "value-free," and those who believe that values are inherent in the nature of psychotherapy. Psychoanalysis has moved from a science-based ideology, through the ethical concerns of Melanie Klein, to a recognition of the "aesthetic" dimension--the creation of suitable forms that can contain psychological distress. From this latter perspective, the antagonism between religion and psychotherapy, initiated by Freud, becomes less acute. Action-based ethical systems, which ignore the inner world, are critically scrutinized. The evidence suggesting there is a relationship between good outcome in psychotherapy and shared values between therapist and client is reviewed. It is posited that through examination of the "ethical countertransference," therapists should become aware of their own value systems and how they influence practice.

Freudian Theory↗
PubMed1997

Dynamically oriented psychotherapy with borderline patients.

This article outlines a basic framework and strategy for a dynamically oriented psychotherapy with borderline patients. Focus includes arrangements and guidelines for psychotherapy, neutrality, the stability of the therapeutic environment, the therapeutic alliance, transference, the countertransference, activity of the therapist, types of interventions, style of interventions, interventions regarding core difficulties, the conceptual framework of anxiety and defense, trends in the psychotherapy, and termination. A differentiation between analytically oriented psychotherapy and dynamically oriented psychotherapy is provided. For one group of borderline patients, a modified analytically oriented approach is utilized throughout the entire treatment. For a second group, there is a switch from analytically oriented psychotherapy to a dynamically oriented psychotherapy, after the therapeutic alliance has become reasonably stable. Two clinical vignettes are provided.

Acting Out↗
PubMed1997

Exploitation of patients: themes in the psychopathology of their therapists.

This clinical paper develops an interpersonal theory of the therapist-patient relationship when boundaries are violated. It describes a clinically useful way to define boundary transgressions. A variety of mutually created dialectical paradigms interact with the therapist's psychopathology when, for various reasons, the therapist who is fully ethically responsible cannot see what is happening. The role of burgeoning aggression, dominance/ submission interplay, envy, and erotized countertransference is explored as forces leading to sexual and nonsexual exploitation of patients. Numerous clinical vignettes are used to illustrate the theoretical issues. Two fundamental axioms of treatment are also described, which, if followed, can help avoid transgressions.

Defense Mechanisms↗
PubMed1998

Psychodynamic psychotherapy, religious beliefs, and self-disclosure.

The intersection of psychodynamic psychotherapy and religious beliefs may present technical challenges for the psychotherapists; particularly if patients request to know more about the therapist's religious beliefs. Contrary to a recent technical recommendation for therapists to self-disclose personal religious beliefs when asked to do so, I suggest that such a request is complex and requires a thoughtful grounding in psychotherapeutic theory. Disclosing personal beliefs to patients runs the risk of being off-task as well as holding oneself out as an exemplar for the patient. Rather than adopt a formulaic response to requests for information, to deepen the understanding of the patient and the work of therapy, the therapist needs a complex understanding based on a careful diagnostic assessment of the patient, as well as an assessment of the current status of the psychotherapeutic venture. The workings of patients' particular transferences are often evident in requests for personal information and require careful evaluation and consideration. Likewise, countertransference elements may influence the type of response offered by the therapist. Using ethical principles as a guide is different from using them as a rule. The nexus of religious belief, psychosocial context, psychotherapy, and self-disclosure provides a potentially rich source of understanding when explored in the psychotherapeutic situation.

Ethics, Professional↗
PubMed1998

Narrative lessons for the psychotherapist. Kafka's The Metamorphosis.

Literature has much to offer the psychotherapist. This paper has discussed some lessons for the psychotherapist contained in Franz Kafka's short story, The Metamorphosis. The therapist, like the therapist-reader of this story, can empathize with Gregor's monstrous change but still must hold him personally accountable. At the same time, the therapist-reader becomes increasingly impressed with the malignant nature of the Samsa household, and its role in generating Gregor's capacity for self-deception. The story also instructs about the paradox of catastrophe: Gregor is treated no less respectfully after his metamorphosis than he was before it. The therapist is thereby reminded of the centrality of feelings in human affairs. The constriction of Gregor's space does not cut him off from human feeling; rather, Gregor's inability to access, know, and take responsibility for his own feelings, especially his destructive ones, results in his constrictedness and detachment. In thinking about the story as dream, or in imagining a patient's account of a reality situation as if it were a dream, unseen mental process and content become more apparent. The disgusting, loathsome arrangements that people make with each other can evoke, be it in the therapist-reader or the therapist, reactions of aversion or hate. Such arrangements become more understandable when the importance, sometimes the necessity, of human attachment is appreciated. And finally, Kafka's The Metamorphosis alerts us to a sometimes but powerful preference and countertransference pitfall: we don't want to be bugged.

Humans↗
PubMed2000

The use of the psychodynamic life narrative in crisis supervision.

The psychodynamic life narrative is a statement that is made to the patient that gives current emotional reaction meaning in the context of his life history, and shows it to be a logical and inevitable product of previous life experiences. Because the patient in crisis characteristically present feeling overwhelmed, confused and needy, there is a sense of urgency and helplessness which impacts on the resident therapist's intervention. Common countertransference reactions which can result are assuming omnipotent control, a grandiose rescue fantasy or passivity. The authors present a clinical vignette to illustrate the supervisory process and its vicissitudes in the use of the psychodynamic life narrative in supervision of crisis work. The early identification of the "rescuing" response led to the rapid formulation of the psychodynamic life narrative and a successful outcome.

Adult↗
PubMed2000

The value of a psychodynamic approach in the managed care setting.

The managed care setting presents significant challenges to all psychotherapists. Psychodynamic therapists, however, experience specific difficulties in this environment. Despite managed care's general hostility toward psychodynamic theory and practice, psychodynamic therapists provide unique and significant opportunities for patients. Psychodynamic training, with its emphasis on careful evaluation, exploration of unconscious conflict, transference and countertransference, and other therapeutic phenomena, enables clinicians to provide an invaluable service to managed care organizations. The case of K., a 45-year-old man, is used to illustrate the ways in which psychodynamic elements of a brief treatment contributed to a successful outcome. The importance of including psychodynamic treatment in managed care settings is discussed.

Health Maintenance Organizations↗
PubMed2000

Psychoanalysis at the millennium.

This article explains and discusses the immense complexity of the psychoanalytic process as it is becoming increasingly understood at the millennium, and offers the possibility that it can be viewed from at least five channels of psychoanalytic listening. The careful ongoing examination of the transference-countertransference interactions or enactments, and their "analytic third" (32) location in the transitional space is extremely important in psychoanalytic practice. We must be careful in our interpretations of the clinical data not to stray any farther from the fundamental concepts of Freud than is necessary, lest we end up with a set of conflicting speculative metaphysical systems and become a marginalized esoteric cult. Freud's work remains our basic paradigm, the core of psychoanalysis, even though his papers on technique and his emphasis on the curative power of interpretation are from a one-person psychology standpoint and his view of psychoanalysis as just another empirical 19th-century science requires proper understanding and emendation in the light of accumulated clinical experience since his time.

Humans↗
PubMed2000

Presentness: an intersubjective dimension of the therapeutic act.

In this article, the author discusses a mode of the therapist's presence as an important dimension within the intersubjective framework. She seeks to introduce the term presentness to denote dimensions of the therapist's explicit usage of her implicit knowledge and the role of her unformulated experiences within the therapeutic situation. The emphasis is on the power of these shared states of mutual reverie and moments of spontaneous responsiveness on the part of the therapist. The author wants to emphasize again that this term describes an important, though not exclusive, dimension of the therapeutic interaction. It does not replace such psychic functions as observation, distancing, empathy, or such modes of object-relating as transference, countertransference or projective identification. The term presentness illuminates the symmetrical dimension of the therapeutic interaction, and its contribution to the construction of "meaningfulness" for both patient and therapist.

Adult↗
PubMed2003

Psychotherapy of Arab patients in the West: uniqueness, empathy, and "otherness".

The study of Arab patients seeking treatment for their psychological problems in the West has previously been underrepresented in mainstream American journals. Notwithstanding various attempts that deal with Arab Americans as a minority group, there has been a paucity of scholarship dealing with Arab patients' unique characteristics related to sociopolitical, cultural, and other factors that impact the therapeutic process for those individuals who are not acculturated to the American way of life. These patients present challenges to their therapists owing to the contrasting cultural understanding and conceptualization of mental illness and therapeutic process. Therapists need to fully appreciate the relationship between culture and psychotherapy. Patients' and clinicians' awareness of differences may contribute to the ability of both sides of the therapeutic dyad to overcome some of the differences encountered when Arab patients are treated outside their cultural domain. A case vignette serves to illuminate how issues of cultural transference and countertransference can be managed for the benefit of the patient and the enlightenment of the therapist.

Acculturation↗
PubMed1983

The impact of patients with chronic character pathology on a hospital inpatient unit.

Inpatient psychiatric facilities are admitting an increasing number of young patients with chronic character pathology. Hospitals must explore the impact these patients have on the treatment facility and the risks inherent in their treatment, including the possibility of decreased milieu specificity, increased staff regression, and loss of cost-effectiveness. These risks are system responses that go beyond individual staff countertransferences. Possible remedies include refined indications for inpatient psychiatric treatment, tailoring of milieu functions to fit individual patient needs, explicit accountability of administrative and supervisory structures, and involvement of families in the formation of the initial treatment alliance.

Acting Out↗
PubMed1984

Staff responses to the pregnancy of a therapist on an inpatient unit.

The author interviewed staff on three psychiatric wards to elicit their response to pregnant colleagues. Staff expressed particular concern about protecting the pregnant women from possible patient assaults. Some staff members were overprotective or unwilling to express anger directly toward the pregnant staff members. Staff also reported increases in jealousy, maternal transference and countertransference, anxiety about the impending separation, flirting with the pregnant women, and joking about sex. The author compares these findings with reports from outpatient settings and discusses potential implications.

Adaptation, Psychological↗