Spontaneous self disclosures in psychotherapy

The closeness and intensity of feeling that develops between therapist and patient raises complex issues related to the therapist's neutrality, the transference, the countertransference, the therapeutic alliance, and the very essence of the curative aspects of the relationship. The issue of the relationship of self disclosure and the evolving transference, countertransference complex is discussed. It is suggested that on some occasions, the pressure a therapist feels to spontaneously disclose something intimately personal is an indication that the therapeutic role has become reversed and the therapist is using the process to heal a vulnerability in himself or herself. The patient unconsciously participates in the interest of safeguarding the treatment process. In such instances the self disclosure need not interfere with the evolving transference. It may lead to great spontaneity in the process and to opening areas of affect previously unreachable. Self disclosures cannot be viewed as technical innovations to avoid stalemates in clinical practice. Rather, they are facts of our clinical life, facts that must be explained and understood rather than judged and condemned.     

Tuning and Practicing the Therapeutic Instrument: The Therapist's Life Experience

This article views the therapeutic use of self broadly as if through a wide-angle lens focusing on the therapist within his or her surroundings. These contextual features can be seen as projections of the therapist's self and therefore useable in treatment. Through an interest in alternative brain functions due to her own struggles with a neurological illness, the author arrived at the idea of utilizing her personal interests which naturally come into the milieu as therapeutic vehicles. Personal interests that are compatible with the patient's character offer alternative modes for experiencing, expressing and regulating affect states. These interests in the expressive arts together with the person of the therapist constitute a medium for rotating attention around unfamiliar parts of the mental landscape. Disavowed or dissociated affects can be unearthed, made conscious, put into language, and treated. This idea in practice nests neatly within recent thinking in psychoanalysis, neuroscience, and the philosophy of science. When language alone is not enough to move the therapeutic process forward, other working knowledge in the therapist's life can be brought to bear as a powerful evocative force for therapeutic change.     

A therapist's pregnancy: An opportunity for conflict resolution and growth in the treatment of children

A therapist's pregnancy is a unique event which holds profound implications for both patient and therapist in any therapeutic relationship, and it inevitably affects the course of the patient's treatment. A number of theoretical and clinical articles have been written over the past 15 years on the topic of the pregnant therapist, but very few have concentrated specifically on the child patient. This article explores the therapist's pregnancy and treatment implications in clinical work with children and offers an in-depth case vignette to illustrate how a child may effectively utilize the experience to work through previously unresolved feelings and conflicts. The therapist's pregnancy can, therefore, provide the child with an opportunity for conflict resolution and growth, if the process is handled in a therapeutically sound and sensitive way.The author would like to thank Ava Siegler, PhD and Jules Glenn. MD for their helpfül suggestions.     

DIRECT SUPERVISION: ADDING COMPUTER-ASSISTED FEEDBACK AND DATA CAPTURE TO LIVE SUPERVISION

This is a critical review of live supervision with emphasis on technical innovations such as earphones or bug-in-the-ear, Teleprompters, and computers. A computer-assisted approach is described that overcomes many criticisms of live supervision. Direct supervision uses a computer monitor to unobtrusively provide information to the therapist about the supervisor's perceptions of the clients' and therapist's behavior, the expected therapeutic behaviors, and the therapist's "on target" behavior. Direct supervision has the advantage over other forms of supervision by providing an immediate, continuous, and permanent record for postsession supervision and for research into the supervisor-therapist-client process. The paper provides several suggestions for research.     

Boundary issues in countertransference: A developmental perspective

In treatment, characterologically disturbed patients evoke affective and behavioral responses that are frequently antitherapeutic. Such responses reflect the therapist's involvement in a reciprocal relationship in which the patient attempts to communicate very early pathogenic experiences. In this process the therapist is induced to act in ways that replicate significant aspects of the patient's first reciprocal relationship. Problematic replications may be recognized and modified when therapists carefully monitor their own boundaries between thought, affect, and action. This developmental paradigm is particularly useful in resolving therapeutic impasses that result from the patient's need to use the therapist as a real rather than a symbolic object.     

Therapist pregnancy and maternity leave: Maintaining and furthering therapeutic gains in the interim

A therapist's pregnancy and maternity leave is a time of multiple transitions for both patient and therapist. This article reviews the literature on therapist pregnancy and its therapeutic implications. It discusses the treatment planning choices of: trial termination, therapeutic hiatus, and temporary transfer. The article further addresses the clinical and administrative issues of planning the maternity leave as well as the issues of time-limited treatment with the interim therapist. It included illustrative case examples based on the author's experience as an interim therapist during a six month maternity leave.This paper in its original form was presented as part of the requirement for The Hunter College School of Social Work: Post Masters Program in advanced Clinical Social Work.     

The Place of Values In Psychotherapy

Psychotherapy is a value-laden process because the very notions of therapeutic', 'cure', and 'health' involve patients and therapists in making value choices. Two hierarchies of health values as they apply to therapy are reviewed. The first guides the therapist in setting limits on pathological behavior and constitutes the so-called 6 D's of pathology: destructiveness, dysphoria, disorganization, deviancy, dependency, and disillusionment. The second illuminates the therapist's role-modeling or ideal-setting function and takes the form of a developmental sequence of positive health values, as derived from Kohlberg's work on moral judgment. These health values, from the lowest to the highest forms, are fit-survival, pleasure-seeking, social-belonging, structural duty, adaptive flexibility, and universal commitment. this hierarchy has important implications for understanding the nature of therapeutic changeand the appropriate matching of therapist and patients     

Clinical supervision for psychiatric nurses

Supervision does not represent merely the acquisition of facts. It is an emotionally charged process that touches on therapists' affective problems, interpersonal conflicts, problems in being helped, and problems in helping (Ekstein). As such, it is a process similar to, but not the same as, psychotherapy. Supervision is necessary for continued professional growth, no matter how skilled the nurse may be. Other mental health disciplines have long accepted supervision as an essential component of professional work. A number of methods can be used to review the therapist's work, including case material discussion, conjoint interviewing, direct observation, and review of mechanical recordings. This can be done individually, in groups, or among peers. A supervisor can be a senior clinician from any of the mental health disciplines. The nurse should not be limited to receiving supervision only from other nurses. Periodic evaluations of the supervisory relationship as well as the therapist's skills are recommended. Supervision is a valuable tool that the nurse therapist should use fully to develop the professional self.     

Being missed and missing: An interactional element of separation/individuation

The intent of this paper is to demonstrate as a therapeutic use of self the selective communication of the therapist's own feelings as enabling a patient to experiencemissing. I focus here on work with a patient who urgently and primarily presented unmourned (unintegrated) separation and loss in her history, in her self and object relations, and thus in her relationship with me. I propose that the therapist's feelings, in so far as they reflect an interactional aspect of the normal separation/individuation process may serve as a basis for expressive, interactive participation by the therapist.     

The self-image in the therapeutic dyad: A case example of mutual growth

The therapeutic relationship is seen as a mutual experiencing of self and other which is growth-promoting for the therapist as well as the patient. Work with a borderline woman during a period of two years evoked strong countertransference reactions in the therapist who, at times, experienced the patient as a mirror. A beginning sense of cohesion in the patient's highly fragmented sense of self found a parallel in this beginning therapist's developing professional identity.     

Countertransference,resistance and frame management in the psychotherapy of a 15 year old anorexic and her mother

Countertransference is a rich source of understanding of client dynamics but can be difficult to detect. A case vignette is used to illustrate how changes in the arrangements of therapy should be viewed as red flags alerting the therapist to possible countertransference. By paying careful attention to the client's derivative response to the therapist's agreeing to a request for a change in appointment times, the therapist was able to understand the unconscious motive behind the request, as well as her own countertransference reasons for participating in the resistance expressed in the request. When, based on this under-standing, the therapist was then able to hold to the framework and maintain the previous appointment schedule, this furthered the treatment by providing a model for introjection and by promoting understanding rather than acting out. In complicated therapy situations where treatment of more than one family member by a single therapist is indicated, such careful attention to the framework and to the client's derivative response to the therapist's interventions is particularly important.An earlier version of this paper was presented before the Annual Conference of the Washington State Society for Clinical Social Work on May 14, 1984.     

Self-disclosure in treatment: What therapists do and don't talk about

In contrast to the traditional view that sees therapist self-disclosure as a form of countertransference acting-out that either makes the therapeutic process more difficult or subverts it completely, this paper will present a self psychological rationale for the selected use of therapist self-disclosure in treatment. It will discuss the nature of therapist self-disclosure, issues in its use, countertransference issues, and its evaluation.     

A Pilot Use of Letters to Clients before the Initial Session

This paper explores the nature of engagement in the therapy process, and proposes that engagement may be facilitated when both client and therapist are able to develop an appreciation of each other's position within the therapeutic relationship. Some ways that a therapist can assist in this process are explored. An experiment is described in which information letters are sent to clients before the initial therapy session, as a possible way to enhance the engagement process.     

The impact of therapist pregnancy on the treatment process

Therapist pregnancy is a powerful emotional stimulus and a real-life event that affects clients and the treatment process. In the present paper, previous literature is reviewed and clinical experiences of the author in a university counseling center are reported to address how therapist pregnancy influences clinical treatment. Although therapists often hesitate in emphasizing their pregnancy, evidence suggests that it is easy to underestimate the importance of the pregnancy for clients. Case examples are presented which demonstrate client responses and the significance of the pregnancy for four female clients. Gender differences in client reactions are not fully understood, and it may be particularly difficult to facilitate male clients in dealing with issues stimulated by the pregnancy. These clinical findings suggest that in a variety of settings, understanding and working with clients' reactions to the therapist's pregnancy can enhance treatment.     

Ego Psychology and Self Psychology in social work practice

Ego Psychology and Self Psychology are compared by examining how each theory would imply different treatment techniques. These differences are discussed at both a theoretical level and in terms of their applications to the same case. At the level of theory, Mahler's and Kohut's views are compared along five dimensions: definition of the problem, motivation, conflict, the nature of the therapeutic process, and the therapist's role in that process. At the level of technique, specific attention is paid to when the differences aid or impede the therapeutic process.     

The Clinician's Cultural Countertransference: The Psychodynamics of Culturally Competent Practice

The purpose of this paper is to define the presence of the clinician's cultural countertransference in the cross-cultural therapeutic dyad, and describe its impact on the delivery of culturally competent services. The recognition of the contributing role of the therapist's own subjectivity in psychodynamically oriented practice cannot be more vital than in the treatment of patients whose culture, race, or class markedly differ from that of the therapist. The cultural countertransference is viewed as a matrix of intersecting cognitive and affect-laden beliefs/experiences that exist within the therapist at varying levels of consciousness. Within this matrix lie: the clinician's American life value system; theoretical beliefs and practice orientation; subjective biases about ethnic groups; and subjective biases about their own ethnicity. The author proposes that these countertransference attitudes are often: disavowed by the clinician; exert a powerful influence on the course of treatment; and though unspoken, are frequently perceived by the client.     

The Use Of Shame and Dread in the Countertransference

Much has been written about paranoid anxieties as these occur in the patient. Less, however, has been written about primitive experiences as these occur in the therapist during the session. This paper recounts a patient's correct articulation of the therapist's self-perception, which, because of its accuracy, initially flooded the therapist with shame and dread. Nonetheless, the patient's perception was able to be used in a way that clarified, in the countertransferance, a piece of the patient's early experience in relation to her mother and strengthened the therapeutic relationship.     

EXPLORING A FOURTH DIMENSION: SPIRITUALITY AS A RESOURCE FOR THE COUPLE THERAPIST

This article explores ways in which the therapist's own spirituality can serve as a resource in couple therapy. Spirituality is defined as subjective engagement with a fourth, transcendent dimension of human experience. This engagement enhances human life and evokes corresponding behavior. Spiritually based therapy may be influenced by three assumptions: that God or a Divine Being exists, that human-kind yearns innately for connection with this Being, and that this Being is interested in humans and acts upon and within their relationships to promote beneficial change. In therapy these assumptions affect how the therapist listens and responds throughout sessions. The authors incorporate a case example illustrating the application of this fourth dimension in couple therapy.     

Marital therapy with couples whose lack of self-sustaining function threatens the marriage

In the hierarchy of internal structures that contribute to a complete, mature sense of self, certain psychic functions are essential. In particular, adults who can maintain a sense of intactness of the self can, by-in-large, provide the following five psychic functions for themselves: self-security, self-realness, self-esteem, self-love and identity. Dr. Dan Buie (1989) has described the lack of these five self-sustaining psychic functions in certain clients and the consequences for the therapist/patient relationship. This paper will summarize Buie's contribution to understanding clients who lack the ability to provide these self-sustaining functions, then apply this conceptual framework to the understanding of certain marital conflicts, discussing aspects of the therapeutic process and the therapist's role with respect to these marital conflicts.