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PubMed1990

A patient-therapist's reaction to her therapist's serious illness.

Clinical attention to a crisis in the therapist's life has been scant. Both therapist and patient are touched by a significant occurrence in the therapist's life. Impact on the psychotherapy process is unavoidable. This paper traces the patient's (who is also a therapist) reactions, feelings, thoughts, and experiences in response to her therapist's acute cardiac illness. These include denial, abandonment, anger, compassion, and concern. Writing as patient, the author is re-reminded of the importance therapists hold in their patients' lives. She discusses her concurrent distancing from the psychotherapy process and the depth of her involvement in it. Writing as therapist, she raises salient questions for the clinician, offers recommendations stemming from her experience, comments about transference components of the relationship and discusses the place of the real relationship. Included is a brief review of the limited literature on the subject.

Attitude to Health↗
PubMed1992

Working through conflict with self-destructive preschool children.

This case history charts the treatment of a preschooler who first presented at the age of three years and ten months with aggressive and self-destructive behaviors. During the initial months of treatment, the therapist focused upon establishing a therapeutic alliance with the child in order to evoke a transference reaction. Compelling evidence of the transference in this case occurred in the ninth month of treatment when the therapist told the child that she would be going on vacation. The child, whose own mother had abandoned him several times, responded with uncharacteristic physical and verbal abuse. Although the child engaged in aggressive and self-destructive play enactments almost from the onset of treatment, these behaviors intensified from the fifth month of treatment onwards, as it became evident that he had entered the working-through phase. Aggressive impulses were shown in his manipulation of toys and other objects, and self-destructive episodes emerged in the child's incessant efforts to jump from chairs and tables, as well as in repeated threats to "shoot" himself with a toy gun. The therapist was sensitive to the child's need to continually repeat and gradually modify these behaviors. She permitted their display without exhibiting shock or alarm, but at the same time, expressed concern for the child's safety and reinforced this concern by setting limits on his unacceptable behavior. Gradually, the child's self-destructive and aggressive tendencies abated. Further evidence that the conflict had been worked through was also seen in the child's ability to express a more realistic assessment of his home environment, one which reconciled the conflict between "good" and "bad" impulses. This advancement in perception was demonstrated by the child's verbal recognition that while his mother was capable of doing "bad" things, she was still his mother and he loved her. Prior to the termination of treatment, both the child's grandmother and teachers reported significant improvement in the child's behavior and linguistic abilities.

Child, Preschool↗
PubMed1994

Parallel process in the supervision of child psychotherapy.

Parallel process is a phenomenon in which therapists unconsciously replicate the problems and dynamics of their clients during supervision. It has the unconscious aim of provoking the supervisor to demonstrate how to handle a perplexing situation. Recognizing and resolving parallel process when it occurs is an important supervisory skill. This paper focuses on the unique characteristics of parallel process in child psychotherapy. It reviews various types and manifestations, discusses several case examples, and outlines strategies for intervention.

Child↗
PubMed1994

Individual and group therapies as constructive continuous experiences.

We began this paper with the conceptualization that individual and group psychotherapies were potentially continuous just as internal and external experiences are co-extensive. We recognized Winnicott's "holding," "regression to dependence," and "The primary maternal preoccupation." In our specific context of individual and group therapies, a state of being, a new construct of one's self can be invented in ways that can overturn the received. Clinician and patient can invent a new state of being and new meaning. For our patient, individual therapy was experienced as impacted space where she could neither be nor invent new meaning with another. "Intimacy" as a problem could not be dealt with in individual work without the risk of decompensation. In group psychotherapy she found no such risks or congestion. Rather, she found space. She was dislodged and group psychotherapy received her by giving her an opportunity to renegotiate who hosts whom. She recognized that group was in the service of the human being and was able to absorb her intolerable conflicts and transfer them without danger to anyone. It was a trusting attitude to the surrounding and was motivated by connectedness toward others. As a result there can be a state of being and the real possibility of thinking as one's own self and for one's self in the midst of others without losing one's newly established self. In a word she could become. Accordingly, our patient was able to work towards amelioration of psychopathological formations and was ready to make appropriate selection for the necessary therapy.

Adult↗
PubMed1994

Critical incidents in psychotherapy.

The critical-incident technique was used to obtain a list of patient behaviors that create special difficulties for the psychotherapist. The list was prepared by a group of seven clinicians during a series of meetings. Included in the list were such items as: insulting the therapist; coming late to the session; threatening suicide; and offering gifts. The list was given to 21 experienced psychiatrists who were asked to rate both the importance and the frequency of occurrence of each incident in their experience. The critical incidents could be divided into five major categories: threat of harm from the patient; criticism of the therapist or the therapy; occurrence of a major life crisis; attempts by the patient to seek friendship or seduction, and miscellaneous incidents, such as being consistently late. When ratings by the experienced psychiatrists were compared with those of 10 third-year psychiatric residents, it was found that the inexperienced psychiatrists in almost every case rated the incident as less important and more frequent than did the experienced clinicians. In terms of implications, knowledge of critical incidents in psychotherapy may provide a source of material for training purposes, may enable the development of modeling procedures for training in communication skills, and may encourage supervisors to focus attention on important therapeutic issues.

Adult↗
PubMed1994

Limit setting: theory, techniques, and risks.

Limit setting is a necessary aspect of clinical treatment but the professional literature on this subject is relatively sparse and does not address many core issues, including some countertransferential and ethical problems raised by the approach. Many clinicians struggle with the "authoritarian" nature of limit setting, especially when they have great power over patients as in a hospital setting. This paper traces the theory of limit setting back to Freud's conception of "acting-out in the transference" and the corresponding need by clinicians to manage nihilistic behavior which threatens the treatment process, whether inpatient or outpatient. When done properly, setting limits makes working with acting-out patients viable, enabling them both to master devastating early experiences and to replace restraint by others with self-control. Techniques are addressed which lead to the responsible and effective use of power, but at the same time observing the social and practical limits inherent in the approach.

Acting Out↗
PubMed1995

Projective techniques as psychotherapy.

Projective techniques, by bypassing the conscious resistance of anxiety and defenses, elicits information about the hidden side of perception and thoughts processes, personality, emotions, and psychodynamic processes. They thus enable an assessment of ego strength and the patient's ability to face unconscious content. The aims of psychotherapy similarly disclose the psychodynamics of symptoms formation and conflicts and help the patient to face them. In some respects the test administration procedure is analogous to the psychotherapeutic process. This makes test administration useful not only for diagnosis, but also as a therapeutic tool, especially in brief psychotherapy and when sharing the results with the patient. The therapist, by translating the results, stimulates the gradual gaining of insight and self-awareness at the patient's own pace. Sharing results may allay paranoid suspicions and fears concerning the test administration and the patient-therapist relationship. The meeting with one's own deep feelings acts as a catalyst in the therapeutic process and saves valuable time. Projective results are especially useful when the interpretations are juxtaposed with content arising in the therapeutic session.

Adult↗
PubMed1995

Unearthing shame in the supervisory experience.

A premise of this article is that the supervisee typically experiences shame in psychotherapy supervision. The purpose is to demonstrate that the discovery and exploration of shame by the supervisor and the supervisee enhance both the therapy and the supervision. The focus is on the supervisor's attitudes and behaviors toward the supervisee's shame. Using a case example, three important sources of that shame are discussed: (1) Shame that evolves from the relationship between therapist and patient. (2) Shame that arises from the therapist's fears of, or actual experience of, not being approved of or admired by an idealized supervisor. (3) Shame inherent in revealing personal material in a supervisory relationship. Six recommendations for exploring shame are offered to supervisors: (1) be alert to the therapist's disguised shame, (2) encourage the supervisee to explore how the therapy and supervision are experienced, (3) demonstrate the qualities of a psychotherapist by assisting the therapist in uncovering personal material that affects the psychotherapy, and (4) create an environment of safety where shame-related phenomena can be discussed with candor and curiosity. Supervisors should also (5) ease insecurities by modeling the activities they seek to encourage, and (6) avoid attempts to dissuade the supervisee of an idealizing transference toward them. Limitations of the recommendations are discussed.

Adult↗
PubMed1996

Enactments: an evolving dyadic concept of acting out.

Unspoken actions between the therapist and the patient have major and often unconscious influences on the psychotherapeutic situation. Mutual transferences can bring about acting-out behaviors that portray transference wishes and defenses within both parties. Such actions tend to replace or overshadow verbalizing intrapsychic strife and in that sense can function as formidable resistance to therapeutic introspection. They also may represent behavioral attempts to communicate significant earlier experiences. Reflection on this dyadic interplay has led to contemporary treatment concepts. Enactment, actualization, and treatment misalliances are behavioral manifestations of urges, conflicts, and identifications and they appear most frequently during regressive periods in psychotherapy. Initially an enactment may include a component of the therapist's reciprocal behavior as a necessary feature of the process, prior to a fuller dynamic understanding and eventual definitive interpretation. Collusion by the therapist, through mutual and continuing acting out or through attempts to re-parent, will encourage antitherapeutic misalliances that can lead to continuing symptomatic behaviors and boundary violations. Continuing self-inquiry is essential to facilitate therapeutic change and we need to be aware that the principal analyzing device available to bring about positive change in our patients, is to be found within ourselves.

Acting Out↗
PubMed1997

Need and responsiveness in the treatment of a severely traumatized patient: a relational perspective.

Severely traumatized patients may exhibit poor functioning and a great deal of dependence upon the therapist. The question is raised as to what such patients truly need from a therapist, and the concept of optimal responsiveness is described. These patients may display complex blends of deficits, resulting from inadequate structuralization, together with pathological internal representations. Their expressed needs in therapy may be true requirements and/or expressions of wishes to be compensated for past suffering and refusal to assume adult functioning. Discerning what might constitute optimal responsiveness to true needs may be further complicated by the propensity some of these patients have for dysfunctional and impulsive behavior. A case is presented that illustrates some of the difficulties in determining how to respond to intense expressions of need, including needs for constant availability of the therapist and for physical contact. It is concluded that although this patient did not need everything from the therapist that she initially thought that she did, her needs were so great that an outpatient treatment situation often seemed insufficient. Despite an overall positive outcome for the patient, the treatment experience was very difficult for the therapist.

Adult↗
PubMed1997

The synergy of group and individual psychotherapy training.

Although this paper has focussed on ways in which group-therapy experience differs from the experience of individual therapy for the beginning therapist, all of the differences discussed are only matters of degree and thus are important in both individual and group therapy. Group-therapy experience tends to enhance the visibility of important aspects of all forms of psychotherapy and therefore should be looked at as a useful tool in learning all forms of psychotherapy. Experience in group psychotherapy should ideally precede or occur simultaneously with initial exposure to individual therapy rather than following afterwards as an option, as is usually the case in current psychotherapy training programs. The most important skill to acquire in learning psychotherapy is the sophisticated ability to listen. To do so involves attending to content, affect, the patient's and one's own verbal language, body language, and meta-communications, conscious as well as unconscious. Group psychotherapy experience early in one's development as a psychotherapist can be a powerful tool in developing this ability to listen. Being part of the group process allows a unique level of intimacy that is probably more equal and vulnerable than in other forms of therapy. The use of the self, and the ability to trust in the process without using theory as a barrier between ourselves and our patients, but rather as a bridge to greater understanding, can all flow from the unique experience of leading a psychodynamic group.

Awareness↗
PubMed1997

Impasses in the supervisory process: a resident's perspective.

The purpose of this paper was to identify examples of supervisory and treatment impasses that occur in psychotherapy training and to examine aspects of their resolution. A self-administered questionnaire was completed by resident volunteers in two Ontario university departments of psychiatry. Despite responses indicating an apparent overall contentment with psychotherapy supervision, resident case vignettes detailed the most frequent impasse situations between themselves and supervisors. The majority were unresolved leading to distressing experiences for residents and failed psychotherapies for patients. Supervision promoting learning, combined treatments, and discussion of similar impasses, while focusing on the resident's immediate concerns and transference/countertransference issues appeared responsible for resolution. This pilot study underscores the need for an enhanced focus on the recognition and repair of impasses and highlights recommendations concerning the need for continuing education devoted to the supervisory alliance. We believe this will increase the residents' ability to effectively treat their patients. This paper emphasizes the experience of residents in psychotherapy supervision. A future study will focus on the supervisor's experience of impasses in supervision.

Adult↗
PubMed1997

Change in the therapist: the role of patient-induced inspiration.

Clinicians experience positive changes in emotion, cognition, and behavior that they attribute to their work with particular patients. This process of change is termed inspiration. The goals of this study are: (1) to demonstrate that clinicians report being inspired by certain patients; (2) to compare inspiring and noninspiring patients regarding the strength of the therapeutic alliance; (3) to explore how the therapist changes as a result of working with the inspiring patient, and (4) to investigate what patient factors are inspiring. Of 300 randomly selected NASW members in the New York metropolitan area working in mental health settings, 84 completed a survey about inspiring and noninspiring patients that included the Working Alliance Inventory. Of these participants, 59 provided narrative responses about ways in which they have changed as a result of their work with inspiring patients. Inspiring patient factors were described by 37. The therapeutic alliance with the inspiring patient was found to be stronger than that with the noninspiring patient. Clinicians described various changes in personal and professional realms. In addition, specific patient factors such as perseverance and the ability to overcome serious obstacles were described as inspiring. The process of inspiration and implication of the findings in this study are discussed.

Adult↗
PubMed1997

Masochism revisited: reflections on masochism and its childhood antecedents.

Masochism, originally described as sexual perversion by Sacher von Masoch, was elaborated by Freud to include personality pathology, and further developed by Bieber and others. The DSM-III included sexual perversion and personality pathology as separate diagnoses, but were totally eliminated from the DSM-IV. It is the author's thesis that the masochist's self-abnegating language is diagnostic--a disguised attack expressing fear, hate, and contempt of others.

Adult↗
PubMed1998

To a beginning psychotherapist: how to conduct individual psychotherapy.

The paper presents a realistic orientation to the practice of primarily insight psychotherapy. The principles, basic assumptions, and practical considerations are nevertheless applicable to all serious psychotherapy. Therapy is here understood not as a science or a matter of technique but as a collaborative and uniquely personal exploration of the patient's difficulties in living. Psychotherapy is thus seen as a search for meaning rather than for cure, with the hope that knowing what they are doing with their lives will enhance the ability of patients to live with more effectiveness and fulfillment. The limitations of therapy and therapists are fully recognized. Specific guidelines for initiating and conducting therapy are designed to promote genuine progress and reduce the risk of errors that are so easily made even by the experienced. As the medium of therapy, the patient-therapist interplay is presented from the perspective of both patient and therapist. The intelligent use of empathy and interpretation and the manifold forms of resistance all receive their share of attention. The paper concludes with a consideration of values, morality, and the importance of recognizing and respecting the spiritual dimension.

Awareness↗
PubMed1998

The evangelical Christian in psychotherapy.

The history of the evangelical attitudes to therapy is complex. Several of the historical roots to a general suspicion of psychological perceptive are explored. Freudian psychoanalysis and fundamentalism were not compatible and for decades no attempt at rapprochement developed. The liberal wing of Christianity made early attempts with the religion/psychiatry dialogue of the 1960s. Drastic changes in the youth of the evangelical, especially on the college campus in the 1960s, broke through some of the resistance. A growing disillusionment on the part of the evangelical in the pew concerning the efficacy of the traditional spiritual approach to relational and emotional problems accompanied these changes. The literalism and rigidity of a paranoid stance toward psychological insights has given way to a kind of chaos. The evangelical person seeks outside the church too. There is no consensus theoretically or practically among the many from within the church who are therapists. There are many strengths in the evangelical. These include family and developmental emphases in psychotherapy. The effective therapist will comfortably explore the religious life of the evangelical as it is relevant to the therapeutic task. Acceptance and elimination of countertransferential bias will foster the honesty and mutual respect that are essential for positive outcomes in therapy.

Christianity↗
PubMed1998

Cultural intersections in the psychotherapy of borderline personality disorder.

Psychotherapy can be essentially considered a journey in which two individuals embark, each carrying a formidable cultural legacy. The psychotherapeutic enterprise then becomes a succession of stops and intersections as the two protagonists struggle to identify their culturally determined behaviors, using culturally determined procedures to take care of them. In this sense, cultural procedures are not a technical term but the appropriate combination of learned concepts, experiential modifiers, and common sense indicators of contemporary realities both at the individual and collective levels. The fascinating and challenging nature of BPD does have a significant cultural component encompassing explanatory, interpretive, pathogenic, pathoplastic, diagnostic/nosological, and service management aspects. It is in the psychotherapeutic arena, however, where both patient and therapist must face a multitude of culturally determined situations that may have a significant impact on the outcome of treatment. Culture can help the therapist to dispose of misleading clinical labels, with obvious advantages for the patient's well-being. Psychotherapy can correct the pathogenic elements of the patient's culture, recognize the pathoplastic clothing of the patient's symptoms, and provide culturally sanctioned and valued success experiences that may increase self-esteem, strengthen stability and, particularly, contribute to the patient's achievement of an identity with which he or she can feel comfortable. Finally, it must be remembered that it is not up to the therapist to offer infallible explanatory models of the patient's plight, but only culturally acceptable premises on which to build such explanations. On the other hand, it is up to the therapist to recognize the "idioms of distress," both physical and psychological, that the patient conveys in the psychotherapeutic context which is, as had been said many times here, totally immersed in the environment of culture. Two vignettes illustrate several of the issues under discussion.

Adult↗