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.     

Psychiatric crises: making the most of an emergency room visit

A hospital-based or comprehensive mental health system may attract many patients for a variety of reasons. Labeling a patient's difficulties as "true crises" or "non-crises" detracts from providing growth-producing insights for the patient and identifying useful management strategies for the therapist. The challenge is to foster the patient's emotional development and to facilitate his entry into treatment or strengthen his established treatment. Making the most out of the emergency room visit means exploring appropriate issues with the patient and discussing the content with any therapist who is involved with the patient.     

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.     

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.     

Play and Impersonation: Finding the Right Intersubjective Rhythm

The following paper examines a client's developmental process through transference, play, and the client's impersonation of the therapist. Winnicott's notion of the intermediate space, current infant research studies, and Jessica Benjamin's concept of thirdness are the organizing framework for the treatment. The author uses a clinical vignette to illustrate a relational perspective in which play and creativity become important developmental processes for both patient and therapist.     

Treating Trauma Through Three Interconnected Lenses: Body, Personality, and Intersubjective Field

The neuroscience of trauma in increasingly oriented to the importance of understanding right brain to right brain dynamics and helping the therapist to respond to implicit communication, which is discussed, as well as Porges’ polyvagal theory. The traumatized patient presents a variety of challenges to clinicians, including a dysregulated autonomic nervous system (ANS), compromised ability to self-soothe and diminished capacity for relatedness with others. Therefore, one effective approach to treating trauma (especially dissociation) includes conceptualizing and responding to our patients through three separate but interconnected lenses: (1) patient and therapist as human mammals—orientation to the ANS, (2) patient and therapist as personalities—orientation to the internal world and, (3) patient and therapist as inhabiting an intersubjective field together—orientation to shared, co-created body/psychological states. The capacity to be guided by countertransference is an especially valuable skill for therapists, as well as the ability to know when they are being experienced as helper or adversary by their patients. Different dynamics driving dissociation and different strategies for responding to the dissociating patient are discussed. Clinical examples are included.     

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.     

INFLUENCE OF THERAPIST SKILLS ON CLIENT PERCEPTIONS OF MARRIAGE AND FAMILY THERAPY OUTCOME: IMPLICATIONS FOR SUPERVISION

Clients seen in two marriage and family therapy training clinics were surveyed regarding treatment outcome. They rated their therapist's skill level on several therapist variables including "experience,""confident,""concerned," how well the treatment used seemed to "fit" their view of the problem and if the therapist seemed to "know how to deal" with their concerns. The variable of "fit" of treatment accounted for 35% of the variance in the client's perception of treatment outcome. "Concerned,""fit," and "knew how to deal" accounted for 36% of the variance in overall rating of the therapist. Suggestions for using these results in supervision of beginning therapists are given.     

Beginning Struggles with Families*

Beginning treatment with families is marked by a sense of struggle between the family and the therapist. The family is seen as testing the therapist and as asking through their behavior questions about the therapeutic process. The therapist is advised to focus intently on the beginning interviews, working toward the point where the family relaxes and decides on an intuitive level to enter therapy. The major hurdle is in dealing with the family's anxiety as the therapist attempts to shift the focus from the individual patient to the family as a whole. Strategy in establishing this shift is outlined     

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).     

Losing Ann: Countertransference Aspects of Altering the Frame with a Long Term Patient Facing Atypical Dementia

This paper chronicles the journey of a long term, suicidally depressed patient’s struggle of growth and survival, only to be struck down by a form of Dementia: Lewy Body Disorder. Focus of the paper highlights the myriad complications and struggles that developed in the countertransference as therapist, patient, family, and medical caregivers, try to ascertain: What is psychological and regressive? What is neuro-degenerative? How can the therapist cope with this confusion while maintaining the frame? The paper highlights how the frame as we know it, is altered to meet the medical and psychological crisis presented and how that alteration impacts the treatment and the therapist’s changing perception of what the work is about.     

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.     

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.     

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.     

Making sense in conversations about learning disabilities

This article describes an integrative, multisystem clinical approach to the psychological and relational problems that develop around learning disabilities. Positioned in relationships with children, families, and schools, the therapist addresses the emotions, interpersonal conflicts, and problematic beliefs that contribute to problems. Using clinical skills to contain and relieve painful emotions, the therapist soothes "inflammation at the boundaries" of relationships among children, families, and schools, depolarizing conflicts within and between systems. Familiar with developmental and educational psychology and developmental neurobiology, the therapist makes this specialized knowledge intelligible to children, families, and teachers. This article describes two specific methods, the chart of strengths and weaknesses and the map of learning functions, which facilitate communication of specialized knowledge about children with learning disabilities. The therapist uses expert knowledge to help members of the treatment system transform blaming, helpless, or hopeless interpretations of the problem into more hopeful constructions, which support healthy development.     

“Supportive” psychotherapy: A contemporary view

In this paper, a brief review of social work literature regarding the technique of psychotherapy serves as a bridge to introduce the way in which self-psychology and the systematic use of empathy as a mode of listening and responding, had effected the conduct of psychoanalytic psychotherapy. A clinical sample, taken from the treatment of a patient who was diagnosed as having a Borderline Condition, is being used to demonstrate that feeling understood firms up the self in a way that enhances introspection and permits the use of interpretations as the therapist's primary mode of communication. The clinical example also demonstrates that when the therapist maintains an empathic position, the patient, even in once weekly therapy, is likely to develop one of the selfobject transferences. Further, that when empathic interpretations are used as the therapist's primary interventions, structural changes are likely to occur in such a way that treatment results in true healing rather than in the fostering of a life-long dependency on the therapist. Only a brief reference is made to the usefulness of self-psychology to the treatment of patients with higher level psychic organization and the important part that anger plays in the process of psychoanalytic psychotherapy.The Shirley Greenberg Memorial Lecture, Delivered at Simmons College, School of Social Work, Boston, Massachusetts on June 9, 1983.     

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.     

The treatment relationship: Real or symbolic?

In response to an article by Gerald Schamess (1981) in which he examines reciprocal interaction between patient and therapist, behavioral responses evoked in the therapist by the client are further explored within a developmental conceptual framework. An attempt is made to assess their effects on the client's development.     

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.