Listening carefully

The inept physical therapist is unable to be with her patient, unable to "move on from the 'I' to a 'we.'" The effective therapist helps the patient make friends with his body and with the cosmos and leaves room for the patient's struggle with the questions of life's meaning brought to the fore by serious illness.     

The uninterpreted rage: Protecting the therapeutic alliance in the treatment of borderline patients

After reviewing differing approaches to the treatment of the borderline patient, this paper describes the treatment of a patient whose negative transferences are not interpreted by the therapist; rather, the focus is on maintaining the therapeutic alliance via the awareness of the kinship selfobject function of the therapist and merger with the idealized selfobject.There is no end unless the bottom of the trough has been reached, unless the thing feared has been experienced. (Winnicott in Casement, 1991, pp. 129–130). As a matter of fact in these cases it is of decisive importance for the psychotherapist to remain clearly differentiated from the core of psychopathology—if he cannot achieve this separation and becomes drawn into the patient's delusions, he loses his tie to the healthy remainder of the patient's psyche and thus his therapeutic leverage. The maintenance of a realistic, friendly relationship with the psychotherapist is thus of crucial importance in the treatment of the psychoses and borderline states ... (Kohut, 1971, p. 30).     

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.     

Returning to psychotherapy with the same therapist: A self psychological perspective

Terminations or interruptions of psychotherapy which have been followed by a patient's resuming therapy with the same therapist at a later time have often been viewed as premature with the implication that the initial therapy has been inadequate or deficient. This paper suggests, however, that a patient returns to the same therapist because the selfobject bond established in the initial treatment is still intact, and that the hiatus between treatments can be a time of further development and strengthening of self structure. Two clinical cases are described which illustrate these ideas.     

The Effects of Suicide on the Private Practitioner: A Professional and Personal Perspective

A patient's suicide has a profound effect on the therapist and psychotherapy with a chronically suicidal patient is particularly troubling. Guilt over one's failure to recognize the warning signs, fear of one's incompetence or irresponsibility, shame that one has failed, and fear of being blamed by the patient's loved ones and by colleagues are feelings that frequently surface and that can result in isolating a practitioner from the very sources of peer support that are necessary in order to resolve the trauma. This article explores the effects of suicide on the private practitioner. It discusses how burnout and vicarious traumatization impact upon the therapist who treats the chronically suicidal patient. Two clinical examples illustrate the impact of working with imminent suicide and the aftermath of a patient's death from a personal perspective. Recommendations are made to help private practitioners maintain equilibrium when working with these overwhelming case situations.     

Institutional transference: a new look at an old concept

In reviewing the early development of institutional transference, the concept was defined as the patient's identifying the treatment relationship with a clinic rather than with an individual therapist and a form of "distancing." More recently, the literature reflects a debate about whether the phenomenon is an outcome of patients' inability to maintain an individual relationship or their adaptation to changing therapists within a clinic over time. In our clinical experience, we have observed that institutional transference is strongly associated with the clinical outcome. In the clinical examples, we demonstrated that being aware of the potential for institutional transference and allowing it to develop can facilitate the development of a more trusting relationship between the patient and clinic staff. Institutional transference can coexist with individual transference and help facilitate rather than hinder the development of a therapeutic relationship. In our experience, the sense of a relationship with the clinic or treatment center is an important aspect of care. Therefore, recognizing institutional transference enables the clinician to pace the development of the relationship with the patient.     

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.     

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.     

Overvaluing the therapist: The search for a good object

Summary In this paper, an attempt was made to relate clinical practice to theory as it provides direction in working with transference manifestations presented by a patient entering therapy with an immediate need to overvalue the therapist. The problem was related to the patient's inability to tolerate separation (object loss) because of failure to develop ego precipitates leading to her own positive self-image. The conditions for developing a positive self-image were outlined. Vignettes from the patient's history were offered to illustrate the problem in practice.     

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.     

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.     

Beyond words: The psychodynamics of a therapy in silence with a twelve-year-old girl

This paper unravels the treatment benefits of continued work with a 12 1/2 year old girl who remained silent during the therapy. The multiplicity of meanings that silence represented for the patient are innumerated. In addition, the utilization of therapeutic tools such as movement therapy and countertransference are discussed in relation to the psychodynamics of the patient's silence. The paper shows how the therapist and the patient were able to reach a core self-space from which to develop and grow.     

EFFECTS OF A FAMILY-ORIENTED TRAINING EXPERIENCE ON THE ROLE OF THE PHYSICAL THERAPIST

This article describes ways in which a family-oriented psychologist contributed to a reconceptualization of the appropriate role for the physical therapist in patient care. The article identifies aspects of the changing role of the physical therapist, specifically its expansion to include skilled psychosocial interaction with patient and family for the purposes of reassurance, support and instruction. A primary shift involved changing from focus on the individual and his or her disability to focus on the patient in the context of his or her family. The article briefly describes elements of appropriate psychological training which can be incorporated successfully in a physical therapy educational experience, and concludes with a case example illustrating the basic points relevant to this type of interdisciplinary collaboration.     

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.     

Spirit Possession and Exorcism in the Treatment of a Bedouin Psychiatric Patient

A male Bedouin psychiatric patient was initially misdiagnosed and treated as a paranoid schizophrenic. The modern mental health care system correctly understood the form of the patient's symptoms, auditory and visual hallucinations. It did not however at first appreciate their content, or cultural significance. The patient had unresolved anger toward his family which was manifested in an angry exchange with his mother. This exchange created guilt and the belief that the patient had sinned against God and was possessed by demons. A psychiatric social worker was able to reconcile the patient with his mother and to incorporate a traditional Bedouin healer, the Dervish, to exorcise the patient. The patient was cured by the Dervish, re-diagnosed as a neurotic by the modern system, and continued successfully with both systems for several months in follow-up treatment before being discharged.     

The mystical hue in clinical practice

The notion of the mystical hue in clinical practice, viewed essentially as therapist tendency to formulate understandings and interventions from a known frame of reference, is considered from the dimensions of theoretical commitment, technical style, and similarity to psychic processes. Consideration is given to reification, the projective fallacy, and the developmental tilt, for their potential reverberations in practice. Emphasis is placed on the need to formulate experience-near interventions related to the patient's subjective state consistent with the reality that existing well reasoned theory is continually subject to revision. A case is presented in which the patient's subjective experience, imbued with a mystical flavor, was best approached from a mystical perspective familiar to both patient and therapist.     

Metacommunications. A missed opportunity?

1. The process of communication is a multilevel phenomenon. Certain levels may be transparent or hidden. 2. Human communication dictates that people not only communicate, but also that they communicate about their communication. In essence, humans metacommunicate. 3. "Meta" instructions provided by the patient are interpreted by the therapist during therapeutic discourse. These interpretations allow the therapist to shape the relationship with the patient. 4. A complementary interactional communication approach allows the patient and therapist to maximize their inequalities to the therapeutic benefit of the patient.     

Gentleman bountiful: Repairing the patriarch

Illustrating a patient's use of the transference as a play-ground... an intermediate region between illness and real life through which the transition from one to the other is made (Freud, 1914), the author presents the case of a man in his late fifties attempting to transcend former male role stereotypes. Using the therapist as a transitional object, this patient experimented, both in therapy and in his social activities, with various patterns in relationships with women, becoming increasingly aware of his dominating benevolence and his concommitant denial of dependency needs. Several new ways for viewing both masochistic and acting-out behaviors are proposed, ways that lead to therapeutic responses tending to convert both to reparative regressions.     

Psychodynamic Issues in the Treatment of Binge Eating: Working with Shame,Secrets, No-Entry,and False Body Defenses

Two clinical moments from patients in treatment for Binge Eating Disorder (DSM 5) are described where a manifest problem with body image difficulty was initially denied. Each patient entered treatment with the desire to lose weight as well as gain a fuller understanding of self and mastery over addictive eating patterns that caused considerable psychological anguish. An integrated treatment matrix of practical, contemporary psychodynamic interventions and more behavioral, experiential and supportive tools allowed each patient to uncover and work through heretofore split off aspects of their bodily selves. Defense mechanisms such as ‘no entry’ fantasies and ‘the false body’ that have recently been described in the analytic literature are applied in formulating each case example. The author underscores how therapists must probe for secrets in the personal and family history that are ‘hidden, but in plain view’ and pursue them in order for the patient to embrace a more coherent, true sense of her/his bodily self. These secrets often contain a less conscious rationale for treating the body poorly and perpetuating hated, shameful and derogatory aspects of body image that may become externalized onto the therapist. These externalizations can further complicate countertransference reactions that must be acknowledged and worked through by the therapist in personal or self-analysis.     

Everything You've Always Wanted Your Clients to Know But Have Been Afraid to Tell Them

The regulations of the Privacy Act of 1974 have had far-reaching effects on Federal Agencies and on their record keeping practices. This article discusses the impact on one counselor and the culminating development of the unique interviewing technique of openly sharing the written record with the client which answers the patient's age-old question of what the therapist is thinking about him and his problems.