Focal psychotherapy and self pathology: A clinical illustration

This paper examines the concept of “focal psychotherapy” as a form of psychoanalytic psychotherapy utilizing essentially the same conceptualization of the therapeutic process as long-term psychotherapy or psychoanalysis, mainly that the primary interventions are interpretive. Since in this treatment process a narrower sector of the psychopathology is reactivated than in long-term psychotherapy, the psychotherapy is restricted to the exploration and working through of a focal conflict precipitated by a recent event which has overwhelmed the patient's characterological defense mechanisms. The case report illustrates the applicability of focal psychotherapy to patients whose core pathology is understood to consist of deficits in the structure of the self rather than structural conflict.     

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.     

‘Bad Therapy’ as a Training Technique: An Empirical Analysis

The purpose of the present study was to gather empirical data to examine the usefulness of an intriguing training technique called “bad therapy”. The technique, developed by Lang (1980, 1982), is utilized in a role-play setting for experienced therapists who are having difficulty with specific clients showing little improvement. The therapist is instructed to disregard his or her usual style of treatment, and instead, within a role-play format with a colleague who plays the part of a client, to try an alternative style of treatment. This new treatment, termed “bad therapy”, instructs the therapist to try to make the client worse rather than better. Interestingly, reports from both the role-play therapist and client indicate that the “bad therapy” session was considered more beneficial than the therapist's usual mode of treatment. As well as empirically investigating Lang's assertion, the present study also attempted to look at different perspectives of bad therapy. Is “bad therapy” a directive to be harmful and destructive, or is it a suggestion to be more daring and to take more risks? Subjects were 56 therapists who formed twenty eight pairs of therapist-client dyads. First, each pair conducted a “session” where the therapist performed his or her typical therapy. Then, therapists in one group (N= 11) were given directives to try to make their clients worse rather than better (“destructive” set), while therapists in another group (N=11) were told to say and do things that they wished to, but never dared (“daring” set). Finally, six therapists were told to simply repeat their usual type of therapy (“control” set). Results indicated that clients perceived the destructive and daring groups differently with the daring group being perceived more favourably, yet more authoritarian. Similarly, therapists perceived the daring and control groups more positively than the destructive group. The results are discussed in terms of training techniques and current trends in psychotherapy.     

Psychodynamic therapy for SUD: Counselor's view

First of all, psychodynamic psychotherapy as treatment for substance use disorder (SUD) works. Ian McLoone, lead therapist with the Alltyr Clinic in Minneapolis, knows that firsthand — he's in recovery from heroin addiction and is in it himself. And despite the fact that addiction therapists aren't taught psychodynamic theory or psychoanalytic psychotherapy in graduate school, where cognitive behavioral therapy (CBT), motivational interviewing (MI) and, to a lesser degree, 12‐Step facilitation are stressed, he became interested in it mainly because of his employer, Mark Willenbring, M.D., a psychiatrist and former medical director of the National Institute on Alcohol Abuse and Alcoholism. We talked to McLoone for this story as a follow‐up to our article on the self‐medication hypothesis of addiction, for which we interviewed its developer, Ed Khantzian, M.D. (see “Psychodynamic psychotherapy: When it helps people in recovery,” ADAW, June 22, https://onlinelibrary.wiley.com/doi/10.1002/adaw.32756 ).     

Countertransference Bias in Child Custody Evaluations Is Just a Horse of a Different Color: A Rejoinder to Martindale and Gould

ABSTRACT

The authors' reply to Martindale and Gould's critique of Pickar's article (2007a, this issue), “Countertransference Bias in the Child Custody Evaluator.” Martindale and Gould's objections to considering an evaluator's countertransference reactions as a potential source of bias are addressed by focusing on these four areas: (1) Whether it is useful to introduce the term “countertransference bias” to identify a potential source of distortion in custody evaluations; (2) How the empirical literature on countertransference in the context of psychotherapy might apply to the child custody evaluation process; (3) Clarification of areas of agreement and disagreement with Martindale and Gould, and (4) The importance of evaluator attempts at “debiasing.” We conclude that gaining awareness of countertransference reactions can only enhance the evaluator's ability to provide the most objective custody evaluation possible.     

“Our Own Little Language”: Naming and the Social Construction Of Alzheimer's Disease

Social meanings and cultural definitions attached to illness, disability, and aging have a powerful influence on the development and operations of medical care as well as the social, behavioral, and therapeutic processes occurring within these settings. Specialized care environments designed to meet the needs of what some would argue is a dramatically increasing population worldwide, those with Alzheimer's disease, have been dominated by a medical model of care where treatment of disease has primacy over person. In contrast to the medical model, the Certified Nursing Assistants (CNAs) at Starrmount (pseudonym) Alzheimer's Unit have socially constructed an alternative to the medical model of care through what I argue is the use of language and a process of “naming and reframing.” In this “different world,” as the CNAs call the world of the Unit, the resident is depicted as a socially responsive actor with a surviving self that is to be treated with respect. Using a symbolic interactionist framework, this paper examines the CNAs' construction and use of a “language of openings”—that is, the language arising out of the lifeworld of the residents—as the counterpoint to the “language of limits” of the medical model. Spoken everywhere but nowhere inscribed as “official” knowledge, this “little language,” as the CNAs speak of it, is the fundamental medium for social interaction in the Alzheimer's Unit.     

Fragments of Modernization: Domestic Spaces Indicating Traditional Dialects in a Modern Speech

This article examines the change in Turkish domestic space through modernization and, in particular, the artifact of lace, as a nonchanging object in Turkish home in its relationship with the “traditional” and the “modern” domestic settings. Thereby it investigates how traditional and modern settings are defined in Turkish society and, this leads to a further analysis of the modernization process in Turkey within the scope of Turkish house and its domestic settings. The aim of the article is to analyze lace as an agent, which is an actant of the change in domestic settings, to read the connection between the daily life of people and social lives of artifacts. Therefore, examining the dialogue of lace with traditional and modern domestic settings provides to deconstruct the network of the artifact, the house and the individual during the modernization process that Turkish society has been through. The theoretical perspective of the article relies on a material‐semiotic approach with an emphasis on Latour's Actor‐Network Theory and, the methodology of the article is based on ethnography: It includes observations and semi‐structured interviews conducted with people from different social environments focusing on the meaning and the use of lace in domestic environment.     

Briefly Noted

The Centers for Medicare & Medicaid Services (CMS) has expanded Medicare beneficiaries' access to telehealth, allowing payment for individual psychotherapy, patient education and group psychotherapy that are delivered in “temporary expansion locations, including patients' homes.” In addition, it will consider adding more services if providers show they are interested in doing this. The April 30 decision will temporarily allow Community Mental Health Centers to offer partial hospitalization and other mental health services to clients in their homes. The CMS previously announced that Medicare would pay for certain services conducted by audio‐only telephone between beneficiaries and their doctors, but has broadened that list to include many behavioral health and patient education services. The payments for telephone visits now match payments for similar office and outpatient visits, retroactive to March 1, 2020. Instead of using a rulemaking process to add Medicare services that may be furnished via telehealth, the CMS will continue to add these during the COVID‐19 emergency on a subregulatory basis, taking into consideration “requests by practitioners now learning to use telehealth as broadly as possible.” And the CMS is waiving the video requirement for certain “evaluation and management services” — the office visits with the doctor — and now these can be provided by telephone only. Some beneficiaries don't have access to the technology for video, or don't want to use it. For more information, go to https://www.cms.gov/newsroom/press‐releases/trump‐administration‐issues‐second‐round‐sweeping‐changes‐support‐us‐healthcare‐system‐during‐covid .     

Does the Therapeutic Relationship Matter? A Follow-up Study of Adherence and Improvement in Family Therapy

A follow-up study of 83 families treated by family therapy at a child guidance clinic was conducted and the relation of client/therapist interaction to (i) drop out from therapy and (ii) improvement was examined. Early terminators were found to differ significantly from continuers as to their ratings of their relationship with the therapist, and trends were found for therapists' feelings to be associated with adherence to therapy. Early terminators were not distinguished by diagnosis, severity of case, or improvement rating. Improvement, on the other hand, was not associated with therapists' or clients' attitudes to each other. It is suggested that these factors are of greater significance in “joining” therapy than in its course.     

Cross Cultural Perspectives in Treating the Gay Male Trauma Survivor

Summary

In recent years, there has been an increased emphasis on cultural considerations in psychotherapeutic treatment. Sound psychotherapy is ideally culturally sensitive and concerned with the context within which the client developed and exists. At the same time it is often difficult for many clinicians to navigate the cultural within the psychological framework. When both patient and clinician share more than one language in common, there are a variety of subtle issues that surface. In psychotherapy, “coordinate bilinguals,” those who learn their languages separately, during different developmental stages and contexts, tend to have greater access to their emotional experiences within their first language. When the client presents with a sexual trauma history, the language spoken during the abuse will also have an effect on the language used in the psychotherapy. The case history of Lucio, a Latino gay male, is discussed in terms of the cultural and psychological elements of his treatment by a bilingual North American therapist. This therapist's psychotherapeutic conceptualizations and treatment approaches are examined and reviewed in a written dialogue/ discussion with a Latino psychologist.     

Identification in democratic society

Identification increases cooperation and fairness (“other-regarding” behaviour) in Prisoner's Dilemma and Dictator Games. While identification explains all the difference in behaviour in nonstrategic interactions, face-to face communication further raises cooperation in strategic settings. This “cooperation-increasing” effect must be traded-off against the “equality-decreasing” effect of communication. Allowing for partial communication only—which prevails in large number settings—our experimental results indicate that discussion produces unequal distributions of outcomes to the disadvantage of those excluded from the interaction. Substituting identification for communication is relevant in democracy for all distributive questions and for public good type settings if equality is valued higher than a partial increase of “other-regardedness.”     

Secondary Popular Culture

In the context of “primary process” assumptions concerning mass distributed culture, the idea of “secondary process” assumptions is developed. A secondary popular culture process (1) is focused on the time period after “legitimate” distribution is conventionally considered complete, (2) treats “finished” cultural materials as raw materials, (3) takes for granted the design and actualization features of “legitimate” production and distribution (which is tantamount to “sacredness”), (4) “turns over” nationally (and internationally) produced wants (“markets”) at the local level for local profit, and (5) creates localized occupational, professional, and stylistic identities which are unanticipated consequences of the centralized producer's work. The idea is then illustrated through a brief discussion of the author's research concerning local popular music performers.     

Briefly Noted

It's not every day that a nationally known “rehab” offers methadone. Recovery Centers of America (RCA) has opened its second medication‐assisted treatment (MAT) clinic — Bravo Medical — that does just this. “MAT is a vital tool in the battle against opioid addictions,” said Melissa Bishop, RCA national director of MAT, last week. “But many people are still afraid to learn more about it because of the stigma attached to this form of treatment.” The public is invited to tour the clinic on Oct. 16 from 12–2 p.m. At this event, families of loved ones from the southern New Jersey and Philadelphia area can tour the Somerdale, New Jersey, facility; see how medication is administered; and learn about the effectiveness of MAT. RCA offers MAT at its inpatient treatment centers and at stand‐alone MAT facilities such as Bravo Medical and the Trenton Healthcare Clinic. RCA offers methadone and buprenorphine. New Jersey State Medicaid is accepted at Bravo Medical and the Trenton Healthcare Clinic.     

WHAT IF FAMILY THERAPY WERE A KIND OF PSYCHOTHERAPY? A READING OF THE HANDBOOK OF PSYCHOTHERAPY AND BEHAVIOR CHANGE*

Editor's Note. This piece by Grunebaum is not an “original article,” although his approach to presenting Garfield and Bergin's Handbook to a family therapy audience is certainly original; it does not meet the usual requirements as apiece for the “Connections” section of the Journal, although it certainly does forge such connections with the mental health world beyond family therapy; and it is not a typical “book review,” and thus, is appropriately described in its subtitle as a “reading,” rather than a review. It is a most creative demonstration of the fact that family therapists can learn a good deal of practical value from their colleagues who are “outside” our field.     

A Typology of Families - Five Family Systems

This typology of families is composed of five family systems named “Two Against the World”, “Children Come First”, “Share and Share Alike”, “Every Man for Himself”, and “Until Death Do Us Part”. Each may occur as a pure form but mixtures are common. Variables such as purity of the system, timing of the emergence of a system and the family's flexibility in shifting from one system to another determine outcomes for sickness or health. The therapist's ability to recognise these systems gives coherence to family therapy and improves its effectiveness.     

“Vygotskian-izing” Psychotherapy

Although Vygotsky’s ideas are applied to dozens of disciplines/practices, psychotherapy is not among them. With few exceptions, contemporary Vygotskians have stayed clear of the subject; and most psychotherapy researchers and clinical practitioners have little familiarity with Vygotsky—despite Vygotsky’s challenge to psychology’s isolation of the intellectual from the affective. Recent manifestations of psychotherapy’s cognitive bias are discussed, showing the need to “Vygotskian-ize” the discipline. The Vygotskian-influenced social therapy, focused on group creativity and emotional development, is presented as an expansion of Vygotsky’s dialectical methodology: method as tool-and-result, the unity learning-and-development, the zone of proximal development of play, and language completing thought.     

Returnees' Perspectives on Their Re‐migration Processes

The return of refugees and migrants back to their country of origin is an important topic on the agenda of Western European governments, as return is considered as the most “durable solution” for the “refugee problem”, and as an instrument with which to tackle “illegal” migration. However, these migration policies generally lack a clear evidence base, as little studies have focused on returnees' current living situations and on their perspectives on the re‐migration process. In this paper we therefore try to listen to returnees' voices, through in‐depth interviews with four Nepalese migrants both before (in Belgium) and after (in Nepal) their return, and with 16 returnees after their return to Nepal. The interviews show how most returnees start with a disadvantageous “point of departure” to realize a “successful” return: mostly, they do not really depart “voluntarily”, and they only have limited possibilities for preparing their return and setting realistic expectations. But also, back in the “home country”, most returnees judge their current economic, social and political living situation as bad, meeting little of the expectations that they set before they returned. The participants consider the support they received through the NGOs' return programmes as minimal, because they are mostly limited to a small amount of financial support, and thus of little significance in these returnees' efforts to rebuild their lives in their “home” country. If return programmes want to make a difference in returnees' lives, they should have two extensive components in the “home” and the “host” country, incorporating in both components an integral approach, including economic, political, social and psychological aspects. Viewing these findings, it is not surprising that most interviewees eventually evaluate their return as unsuccessful, and many returnees consider re‐emigration, all of which clearly questions the current basis of worldwide migration policies.     

How Creative Contributions Emerge Over the Lifespan

The starting point for this article is, What are the hegemonic models of man and woman that educational practices are orientated toward in gypsy communities (models that are often in conflict with mainstream schooling institution's models of socialization)? We do not find the collectivism/individualism approach for explaining socialization in minority cultures helpful, for it can lead us to misunderstand the continuous process of change through which communities challenge existing power relations and thereby change society. The alternative proposed here is the analysis of the role of multivoicedness in the process of cultural change, hybridation, and resistance. A set of conversations with members of a Spanish gypsy community give us a “text” where multiple voices contribute, showing a mixed culture where “traditional” voices are in a constant dialogue with “modern” voices. Minority culture cannot be interpreted as a “traditional” culture, for minority culture includes voices of the hegemonic culture in various different forms and provokes hybridation as differentiation, creating a complex framework for children's socialization.