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.     

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.     

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 therapist's pregnancy: Impact on the treatment process

As soon as she becomes aware of her pregnancy, the therapist is confronted with a barrage of issues involving her identity, integration of roles, maternal identification, and redenfinition of important relationships, including those with her patients. While she works at becoming aware of and responding to the dramatic emotional and biological changes of pregnancy, and emerges with corresponding maturational adjustments, her patients enter an often stormy period of therapy in which they respond to the changes in the therapist's appearance, the threat of the growing infant, and the reality of the therapist's needs and inevitable absence for maternity leave. The special event of the pregnancy alters the therapeutic setting and affects both the transference and coun-tertransference, initiating reverberations in the therapeutic relationship which provide opportunities for marked advances in therapy.     

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 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.     

Clinical supervision: Its role in “Containing” countertransference responses to a filicidal patient

This paper illustrates the role of supervision in processing countertransference responses with might have disrupted the therapist's empathy with a patient who had killed her child. The clinical material demonstrates how the therapist's responses of initial denial and subsequent disgust and fear were dealt with in supervision. As a result, the treatment process led to genuine, albeit limited, therapeutic change in a patient with severe character pathology.This paper is developed from a presentation of the case of Mrs. Jay at Department of Psychiatry Grand Rounds, University of Cincinnati College of Medicine, on May 2, 1989.     

To Tell or Not to Tell: The Disclosure of Events in the Therapist's Life to the Patient

Happy or disturbing events may occur in a therapist's life during the course of treatment that intrude on the therapeutic process whether or not their true nature is disclosed to the patient. Therapists are not immune from experiencing acute, chronic, and even terminal illnesses, divorce, remarriage, adopting a child, mourning the death of a parent or significant other, or major accomplishments. In many instances such events affect the treatment process by disrupting appointments, necessitating sudden absences, restricting a therapist's emotional availability and physical stamina, or altering the therapist's mood and affect. In other instances, patients may be aware of such events, at least unconsciously, because of subtle changes in the therapist. Drawing on self psychology and intersubjectivity this paper explores the reasons for therapist self-disclosure of these events based on an assessment of the patient's developmental needs and the nature of the transference. It will discuss ways of making such disclosures therapeutic.     

Telephone sessions in the treatment of a child during the therapist's absence because of threatened miscarriage

This paper concerns a specific experience during the treatment of an eleven year old boy when the therapeutic work was interrupted by the therapist's threatened miscarriage which confined her to bed. The patient had been traumatized at about the age of four when a younger sibling was born. Following the birth of the sibling the mother became depressed and was hospitalized for close to a year. Accordingly, the therapist's illness reevoked the patient's early trauma serving to fuse the original event with the interruption of the current treatment. This afforded an opportunity for demonstrating to the patient the persistent effects of the first trauma and the evidence of the unconscious fantasies deriving from it. Under the circumstances it was decided to continue the treatment by telephone.     

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.     

Dimensions of Cross Cultural Treatment with Late Adolescent College Students

This paper addresses the need to develop culturally sensitive services on university campuses with a student population that is rapidly becoming more culturally diverse. It explores the different psychological paradigms of Western and non-Western cultures, the adolescent developmental process within diverse cultural constructs and the notion of self cross-culturally. Clinical practice implications in cross-cultural treatment are investigated. These include the therapist's self-disclosure, resistance and countertransference issues, verbal and non-verbal communication in the therapeutic relationship, and the dynamics of power and authority. Two short vignettes illustrate some of these clinical issues and emphasize the value of the therapist's knowledge and awareness of cultural differences as well as the importance of their willingness to modify more traditional clinical practices to fit diverse cultural paradigms.     

Abstracts of the Scientific Programs of the American College Health Association Fifty-Seventh Annual Meeting May 22-25, 1979, Washington,D.C.

Abstract

This article focuses on a therapeutic approach to help women deal with the feelings of grief and guilt they may feel as a result of a voluntary termination of a pregnancy. Available medical and psychological literature indicates that, from a public health perspective, significant psychological problems related to an abortion are “minuscule.” Several women the author saw during the 1992/93 academic year who considered themselves to be extremely religious and prolife had undergone elective abortion. They experienced tremendous guilt and grief 4 to 6 months after the procedure. The author recommends that college health center medical and counseling providers who must deal with this issue help the woman validate her loss by revisiting the site of her abortion to reflect upon the experience and to hold a Gestalt dialogue with the fetus to end the relationship. The provider or someone else should accompany the woman to the site because of the increasing potentiality for violence on the part of prolife protesters.     

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.     

Manifestations of the therapeutic alliance in children and adolescents

Building the therapeutic alliance is a creative process and is a central issue for all age groups. In the absence of an alliance, there can be no therapy. The alliance contains many primitive sources for collaboration with the therapist. It is a combination of both rational and irrational elements. The therapist's awareness of developmental issues and defense mechanisms are utilized to guide one along the pathway of productive therapy. In addition, the unique psychodynamic factors are considered when working with children and adolescents. The clinical examples distinguish pitfalls which are destructive and could be avoided, in contrast with understanding and responding appropriately to the verbal and nonverbal communications of the young patient.This paper was presented to the International Conference for the Advancement of Private Practice of Clinical Social Work, Rio de Janeiro, Brazil, August 1987. Ms. Marcus is in private practice in New Orleans.     

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.     

A Sea of Trouble: A Relational Approach to the Culturally Sensitive Treatment of a Severely Disturbed Client

In this article we will show how a relational approach provides a conceptual framework that shapes and informs culturally sensitive practice with a severely disturbed client. We argue that a relational approach facilitates therapeutic action through the intense focus on countertransference, the close attention to enactments, and the therapist's authenticity and self-disclosure. Additionally, we emphasize that a therapeutic matrix that includes the cultural, racial, socioeconomic, and institutional factors, increases the likelihood clinicians will attend to what Perez-Foster calls their dissociated and disavowed personal values. We present a case that had a less than satisfactory outcome where the therapist found herself in a sea of trouble. The case illustrates how a relational approach enhanced the therapist's understanding of the case and allowed her to continue to work with a difficult and challenging client. We conclude by suggesting that our conceptual understanding of this case exemplifies a necessary and appropriate focus for future social work research and practice.     

Integration and alternatives: Some current issues in psychoanalytic theory

The first great bridge between psychoanalysis and social work came with the concepts of ego psychology which provided a synthesis between the worlds of the social order and the psychological depths. Current psychoanalytic theorists now question whether any one psychological theory is sufficient to describe the complexity of human experience, and suggest that each theory has a piece of the truth because it states something that is correct about the patient at a particular time in the treatment. Adherence to multiple theories makes a complex problem for the clinical practitioner, who must decide from which perspective to respond to the clinical material of the moment. Psychoanalytic theorists are also questioning the degree to which it is actually the content of the therapist's interpretations which brings about change in the patient. This article suggests that these developments in psychoanalysis, with their emphasis on therapeutic flexibility and the importance of the relationship will renew and reinvigorate the bridge between psychoanalysis and clinical social work.An earlier version of this paper was presented at the First Clinical Conference of the National Federation of Societies for Clinical Social work.     

The celebration of death in group process

This paper discusses the mobilization of group resources in facing death. It delineates the evolvement of group process when patients and therapist learned of the oldest member's terminal illness. It deals with the group's commitment to his request for help in dealing with his last life crisis by being actively with him through his hospitalization and last rites; the commitment to death with dignity; the group's responses to the therapist as role model in dealing with death and seeing a facet of her which had not been evident to them within the confines of the office, the working through of the patients' and therapist's feelings of loss of loved ones particularly the father; and the countertransference resistance which resulted and its effect on group process.