Neuroscience and Therapist Self-Disclosure: Deepening Right Brain to Right Brain Communication Between Therapist and Patient

Schore and others have written extensively about the importance of unconscious implicit right brain to right brain communication in (1) driving therapeutic change and (2) understanding and working with the patient’s autonomic nervous system (ANS). Porges, who has re-conceptualized the ANS as a system arranged hierarchically rather than organized around balance, has been extremely influential on clinicians interested in neuroscience. Schore’s and Porges’ theories are discussed in order to make the case that therapist self-disclosure is a powerful and useful technique entirely consistent with their work.     

The trainee and the borderline client: Countertransference pitfalls

Acknowledging and overcoming hostile countertransference is a major problem in treating borderline personalities, especially for clinicians in training. Borderline personality dynamics and transference/countertransference phenomena are described, and a compendium of trainess' negative countertransference reactions is offered, following Maltsberger's and Buie's (1974) schema. Myths of omnipotence, seen as antecedents to countertransference reactions, are discussed briefly. A case example illustrates some of the ways that a trainee may inadvertently foster a negative transference/countertransference experience; it also discusses the roles of supervision and consultation in explicating the particular difficulties that the therapist and patient created. The necessity for and nature of limit-setting with borderline patients is noted.     

NEURO-ONCOLOGIC PHYSICAL THERAPY FOR THE OLDER PERSON

Due to the uncertainty of the course of diagnoses, patients with neuro-oncological malignancies present challenges to the physical therapist. At times, the presentation of impairments and disabilities of these patients with neuro-oncological diagnoses do not necessarily coincide with the involved area of the brain or spinal cord. It is our intention to provide guidance to the physical therapist who will be working with these patients with neuro-oncological diagnoses, in hopes that their encounters will be more productive and meaningful. This article describes a brief overview of common central nervous system malignancies, its medical treatment, as well as possible complications and side effects that would need to be considered in rehabilitating these patients. Special consideration is given to the elderly patients with neuro-oncological diagnoses. Pertinent physical therapy assessments and interventions are discussed.     

Difference and Diversity:

Some therapists believe that they should treat gay and lesbian couples ôjust like heterosexual couples.ö Others hold the view that same-sex couples are completely different from heterosexual couples and that only specially trained therapist can work with them. This paper is an attempt to over come the lack of information about gay and lesbian couple by describing the differences between heterosexual couples and homosexual couples; differences between gay couples and lesbian couples; diversity within both lesbian couples and gay couples; and the therapeutic implications of these differences. The discussion of differences has powerful political implications and is embedded within a larger context of belief systems about gender and sexual orientation. Therapist needs to protect against categorizing, essentializing, or over generalizing about gay and lesbian couples. Although heterosexism, homophobia, and sexism affect the dynamics of all gay and lesbian relationships, it is important to recognize that age, class, race, ethnicity, and physical ability, as well as the dynamics of each individual couple, make each relationship unique. The therapist, whether lesbian, gay, bisexual, or heterosexual, should be familiar with issues specific to lesbian and gay experience within the dominant society, and, at the same time, be attuned to the idiosyncratic nature of individual couples.     

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.     

Breaking the race barrier

Through the reflective process of analyzing one's own feelings and reactions to the ethnic minority patient, the white therapist develops an inner clarity that serves as a resource to cope with the unique conflicts one must confront in interracial practice. Only when the therapist has come to some resolution of his or her own feelings about the plight of ethnic minorities in this country can this acumen develop. Although the therapeutic skills applied in psychotherapy with ethnic minorities are in no way different from overall therapeutic skills, certain techniques may be especially useful in interracial practice. For instance, a discussion of the meaning of race and ethnicity in the relationship may curtail racial distortion, prevent stereotyping, and lead to the creation of a therapeutic alliance. When dealing with transference and countertransference issues, the therapist must be particularly attentive to the representation of these same distortions and stereotypes. Formulating clinical problems from dual perspectives, theoretical and sociocultural, is an arduous, but necessary task. Finally, the white therapist must be able to view ethnic minority patients as individuals. Although these patients cope with special problems which must be acknowledged and dealt with in therapy, the therapist must realize there is a common ground on which to communicate. On this common ground, therapists discover the foundation of interracial clinical practice is the ability to accept and respect their patients and themselves as individuals who may have similar anxieties, problems, experiences, and goals. It is through the recognition and sharing of the fundamental human bond that ethnic and racial differences, which may have detrimental effects on interpersonal relationships, are transcended.     

A nursing-centered treatment team in inpatient medical psychiatry

1. Nurses have the most extensive direct contact with their patients, yet in the traditional physician-centered model, they are often excluded from decision making. We have developed a new model of patient care with the nurse as the primary therapist and contact person, as well as the individual who cares for each patient's physical needs. 2. Out team approach improves efficiency, integration of care, and staff unity, which can be especially helpful for patients with personality disorders. 3. Patients appreciate the approach and are better able to increase focus on treatment when the physicians are not present in the ward.     

Containing and the patient's observation of the therapist's countertransference

Projective identification has received much attention for its ability to elucidate certain types of countertransference reactions. However, many severely disturbed patients are unable to benefit from the insight derived from interpretations based on projective identification. For many of these patients, the initial benefit of therapy is based on the containing provided by the therapist tolerating the countertransference rather than insight based on interpretation. Denis Carpy (1989) has written that the patient's observation of the therapist's tolerance of the countertransference helps to build psychic structure in the patient. In this article, the author reviews Carpy's position and then illustrates the value of the patient witnessing the therapist manage his countertransference using the case example of an adolescent in residential treatment.     

Parallel process: Emotional and physical digestion in adolescents with eating disorders

Abstract

This paper explores the emotional processes involved in psychoanalytical psychotherapy with adolescents with eating disorders. The central discussion is of two clinical examples, both of whom were seen by the author at the initial point of engagement with the therapeutic process. Through paying attention to the qualities of transference and countertransference, the idea of parallel physical and emotional processes is seen to emerge as central to the understanding of these two young people and their difficulties. The second half of the paper goes on to develop a comparison between the characteristics of the object relations of the two adolescent patients and the quality of early object relations in babies who have feeding difficulties. The latter is discussed with reference to infant observation, particularly the author's study of 'Five infants at potential risk'. The conclusions drawn are, first, that the therapist needs to take into account, in the countertransference, the 'pull' towards responding to the patient collusively, or through repeating an invasive experience and, second, that the patterns of object relations which are seen in the adolescents and experienced by the therapist in the countertransference relate to prototypes of specific defensive configurations that can be described, through observation, as occurring in early infancy.     

Relationality,Intersubjectivity, and Culture: Experiences in a Therapeutic Discourse of Virtual Kinship

The contextual vision of relational therapies needs to expand beyond the therapeutic dyad to include the cultural context and the indigenous beliefs and practices that can impact on the relationship. An example of this claim is the “virtual kinship” discourse common in some sectors of Turkish society, which involves the use of a kinship idiom in interactions with nonkin, especially across class and gender lines, so that an implicit code governing social reciprocities in actual kinship relations can be invoked. This article provides clinical examples of its use by patients who differ in class and gender from the therapist. Also discussed are the impact of the discourse on the therapist and the way in which the discourse serves to create an intersubjective space for the cocreation of therapeutic meaning.     

Picking Up the Pieces After the Sudden Death of a Therapist: Issues for the Client and the “Inheriting Therapist”

The death of one's therapist can be considered a traumatic event for the patient. The closeness of the relationship between therapist and patient, especially if the relationship is long-term, makes the loss analogous to losing an intimate attachment. This article will explore the complexity of issues involved for the patient who loses a therapist due to sudden death and examines the issues for the inheriting therapist as well. Case examples will be used to highlight some of the more stressful areas of practice in this difficult transition.     

Erotic and pseudoerotic elements in the treatment of male patients by female therapists

This paper describes some aspects of the clinical encounter between the male patient and the female therapist. Examples are given of transference involving erotic, as compared to pseudoerotic (dependency or aggressive) themes. Countertransference and countertransference problems are discussed.     

The Therapeutic Pyramid: A Common Factors Synthesis of Techniques,Alliance, and Way of Being

Common factors in therapy such as the therapeutic alliance and client motivation have been found to account for more change than therapy models. But common factors have been critiqued as only lists of variables that provide little practical guidance. Some researchers have demonstrated that certain common elements (e.g., the therapeutic alliance) account for more variance than others (e.g., techniques), suggesting that some factors should be emphasized over others. Such findings suggest the need for alternatives to model‐based therapy, with one alternative being meta‐models, or “models of models,” that focus on how therapeutic factors interact with each other to produce change. The purpose of this article is to propose a meta‐model describing the relationship between two specific common factors—the therapeutic alliance and interventions. We also propose a new factor—a therapist's way of being—that we believe is foundational to effective therapy. The model is proposed in pyramid format, with techniques on top, the therapeutic alliance in the middle, and therapist way of being as the foundation. The hierarchical relationships between these three concepts are discussed, along with implications for training, research, and therapy.     

Social media,empathy and interpersonal skills: social work students’ reflections in the digital era

ABSTRACT

This paper examines second-year social work students’ (n = 19) reflections on empathy as part of an interpersonal skills course at a regional university in Australia. Students were asked to consider their personal, online and classroom experiences, before responding to a reflective learning prompt: ‘Online communication is killing connection: (the Facebook Like symbol) does not equal empathy’. Qualitative analysis of their responses identified tensions between students’ engagement with social media and their developing understandings of empathy. Students reported an ease and confidence in the use of social media, but were also aware of the risks associated with perceived anonymity, shifting boundaries and an absence of audial and verbal cues in establishing context and quality of communication. Their reflections also suggested that the range of stimulus material used in the interpersonal skills course—including podcasts—had increased their social media awareness and their desire to improve their online interpersonal skills. The implications for professional and pedagogical objectives, as well as curriculum design are discussed.     

Clients’ perceptions of marriage and family therapists’ way‐of‐being: a phenomenological analysis

Previous research highlights the influence of therapist factors on treatment outcomes. One therapist factor proposed as fundamental to the process of therapy is the therapist's way‐of‐being, a relational concept that refers to how the therapist regards a client—either as a person or object (Fife et al., [2014] Journal of Marital and Family Therapy, 40, 20–33). Although this case has been made conceptually, there is little empirical research on therapists’ way‐of‐being with clients. The primary purpose of this research is to investigate clients’ perceptions of their therapists’ way‐of‐being. Utilizing a common factors perspective, the study seeks to explore: (a) how clients experience their therapists’ way‐of‐being and (b) the influence therapists’ way‐of‐being has on clients’ engagement. Phenomenological methods were used to gain a nuanced understanding of the phenomenon. Qualitative data were collected through semi‐structured face‐to‐face interviews with clients (N = 10) who received individual therapy from a marriage and family therapist. Results were organized into two main themes: core tenets (attunement, congruency, and aligning with clients) and operational tenets (providing affirmation and validation, balancing flexibility and structure, and accomplishing goals). Findings are used to make a case for adding the concept of way‐of‐being as an overarching construct for several well‐established therapist factors. Clinical and training implications are discussed.     

The therapist who is perceived as "spiritually correct": strategies for avoiding collusion with the "spiritually one-up" spouse

Marital and family therapists who are perceived by the community as having a strong spiritual orientation face unique and difficult challenges. Clients who seek their help often bring a mix of expectations that can create a situation in which the therapist may struggle with multiple roles, some not of his or her choosing. These expectations are especially challenging when one spouse views him-or herself as "spiritually one-up" and wants the therapist to form a spiritually based coalition against the other partner. This paper describes the various dilemmas that therapists may face when clients perceive them as having spiritual expertise and presents strategies that can be used for avoiding these dilemmas. A case study illustrates the use of these approaches.     

A Client Perspective on Therapist Self-Disclosure

Abstract

Options of “coming out” in differing therapeutic modalities are considered. Modalities considered include traditional psychotherapy, alternative therapies, and managed care systems. Therapist disclosure situations are discussed from the viewpoint of both client and practitioner. Vignettes describing therapy experiences of adult lesbian and gay clients in a variety of clinical settings are presented. Clinical issues pertaining to therapist disclosure of sexual orientation receive consideration in terms of client self-determination as well as in terms of the options or limitations imposed by different modalities. Distinctions are drawn between disclosure in predominately lesbian and gay practice settings and disclosure in predominately heterosexual settings.     

An Overview of Three Models of Marital Therapy

In this article three models of Marital or Couples Therapy are described. Framo's approch to working with couples illustrates Psychoanalytic Theory, Stuart — Social Learning Theory, and White — Systems Theory. For each model, the theory and the ensuing practice are discussed, with attention to the factors that lead to change, assessment, interventions, the role of the therapist. Each is placed within the Bernal and Baker (1979) level of intervention framework. Strengths of each model are highlighted. Each therapist's own style in session is described.     

THE POLITICS OF FUNCTIONAL FAMILY THERAPY: A FEMINIST CRITIQUE*

This paper examines the political processes inherent in Functional Family Therapy (FFT). It argues that this model of family therapy takes a covert political stance which reinforces traditional gender roles in both family and therapist. Of particular interest are FFT's affirmation of existing interpersonal functions in the family, as well as suggested therapist use of self. The implications of this stance are discussed, as well as recommendations for change.     

Prejudice Exposed On Stephen Mitchell's Pioneering Investigations of the Psychoanalytic Treatment and Mistreatment of Homosexuality

Stephen Mitchell's two early papers on the psychoanalytic theory and treatment of homosexuality show characteristic Mitchell qualities—an astounding intelligence, a theoretical syncretism, an unusual ability to fine tune his sense of clinical case examples to particular theories. Surprisingly, they also show a serious commitment to some of the principles of ego psychology. In these papers, Mitchell is perhaps the first analyst to challenge the distinctly unpsychoanalytic pathologizing of all homosexual orientation based on developmental origins characteristic of all sexualities, as well as the distinctly unpsychoanalytic clinical practice of trying to change sexual orientation and behavior in patients rather than helping them to achieve self-understanding and the diminution of conflict.