Transference and countertransference reactions in the psychotherapy of pathological gamblers

Traditionally, in psychodynamic forms of treatment, the patient's relationship with the therapist is central to eliciting and exploring the patient's characteristic ways of thinking, feeling and behaving. Research has increasingly demonstrated the significance of the therapeutic relationship to the treatment outcome. Since little has been written about the therapist-patient relationship in the treatment of pathological gambling, we shall describe what we have found to be some of the common and problematic transference and countertransference reactions and interactions. Both positive and negative transferences and countertransferences will be discussed not only as obstacles to successful therapy, but as tools for understanding patients' conflicts, defenses and reasons for gambling.     

Issues in Psychotherapy with Clients Affiliated with the Opposing Side in a Violent Political Conflict

The therapeutic dyad of clinician and client affiliated with rival groups in a violent conflict shares many features that complicate psychotherapy with persons of different ethnic, racial, and cultural groups, including lack of knowledge, negative stereotyping, differences in fundamental values and world views, and power differentials. Although a great deal has been written about these matters, very little has been written about the therapeutic dynamic where therapist and client are affiliated with different sides of a violent political conflict. Based on the sparse literature on the subject and on the clinical experiences of the author and her colleagues, this paper discusses three features that characterize this dynamic, which do not appear in the same way in therapy involving dyads of different races, ethnic groups, or cultures. These are the presence of the “enemy” in the consulting room, the therapist’s feelings of mistrust towards the client as a representative of the opposing group, and the client’s feelings of guilt towards the therapist as a representative of the injured group. The impacts of each feature on the therapist, client, and the therapeutic encounter are explored and suggestions are made for dealing with them. The hope is that professionals’ awareness of these issues will help improve the quality of psychotherapy with persons on the rival side of a violent political conflict.     

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.     

Structuring Home-Based Therapy: Four Phases to Effective Treatment

ABSTRACT

Home-based services are gaining more popularity than in years past. Therapists going into the home are exposed to various treatment issues that differ from those in a clinic or office setting. One of these issues is that of structuring the therapeutic process. Much has been written about the structure and stages of clinic-based therapy; however, little is known about the process of home-based therapy. This paper will delineate four phases of home-based therapy which the in-home therapist can use as a guide to provide faster and more effective services.     

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.     

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 Last Time: A Metaphor For Leaving*

Much has been written about the beginning phase of family therapy, little about the end. Joining may be said to set the tone for later therapy, ending establishes directions for the future. As such, this last and crucial phase of therapy warrants careful study. This paper examines the importance of the last session of therapy for both family and therapist, and illustrates techniques which may facilitate future change.     

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 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.     

Implementing a short-term family support group

1. Although family involvement has been increasingly recognized as a vital component in the treatment and care of the mentally ill, little has been written about efforts to provide education and support to the families of patients hospitalized for short-term evaluation and treatment. 2. The family education and support group provided emotional support and critical information to increase family members' coping and problem solving abilities, and enabled them to return to a pre-crisis or higher level of functioning. 3. The family education and support group not only enhances the assessment and planning phases of the nursing process, but it also can serve as a useful intervention for strengthening the patient's major support system.     

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 Extramarital Affair: A Language of Yearning and Loss

This paper presents an extramarital relationship as an experience of self-enhancement, not of pathological conflict. It will suggest that the simultaneous relationship with the lover AND an empathically attuned therapist can be healing for the patient. It is seen as often an opportunity for essential developmental needs to be fulfilled when damaging failures in the bond between child and caretaker have restricted the vitalizing atmosphere of mutual influence that results in unrecognized subjectivity. Rather than viewed as a reality-escaping midlife enactment, these relationships can be better thought of as efforts to revisit the traumatic experiences that have created the organizing patterns that have limited a patient's self-development. An extramarital affair is often about yearning and loss and the freedom to enact one's own desire.     

Nurturing Nature: Exploring Ecological Self‐of‐the‐Therapist Issues

Much has been written about the systemic effects of families and culture on individual well‐being. Seldom discussed, however, are the systemic effects of our relationship with the larger ecological system in which all families and cultures are embedded. A case is made for the importance of nature in family therapy. Furthermore, before therapists can effectively address ecological issues in therapy, they need to address various ecological self‐of‐the‐therapist issues that will influence their clinical practice. A series of questions are asked to help guide therapists in this exploration, and practical suggestions for incorporating nature into MFT clinical practice, training, and research are made.     

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.     

Stories of AIDS: The use of narrative as an approach to understanding in an AIDS support group

This paper shows how the co-creation and telling of narratives helped members of an AIDS support group transform their unique and separate experiences of suffering into shared insights, intense connections and comfort. Examples of narratives are drawn from the author's experience as a co-leader of a support group for gay men living with AIDS. Current literature on group work with persons living with AIDS is embedded in a modernist orientation in which the therapist is the scientist/expert, the client has the problem and the therapist helps the client's through exploring and interpreting the client's story according to a superseding theory (Gergen and Kaye, 1992). This approach emphasizes the need for leaders to maintain objectivity and emotional distance to avoid burnout (Gabriel, 1991; Grossman and Silverstein, 1993; Tunnell, 1991). In contrast, in a post-modern therapeutic approach, there is no privileging of the therapist's narrative and the traditional hierarchical relationship is replaced by a mutual effort as therapist and client together develop stories that translate and transcend experience. Using the AIDS work as illustration, this paper offers a post-modern, narrative approach to group work and shows how persons living with AIDS can use narrative to move beyond finite structures and the limits of life.This paper couldn't have been written without the help of the group members and my co-leader Sally Bowie. I want to thank them and other friends and colleagues-particularly the members of my Philosophy Study Group for their suggestions and support.The paper is dedicated to the memory of Jack, Paul, Mark, Alex, Richard, Hugh, Stan, Tim, Michael and Bill—all members of the group who have died and to Dean who, though not a member of the group, also died of AIDS and like the others—taught me much about dignity and courage, about being gay and about living with AIDS.     

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.     

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.     

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.     

Contract curve or implicit contract: Which will a union choose?

While much has been written about implicit and efficient (contract curve) contracts, little has been written about which contract a union will choose. This study examines how a democratic union chooses between these contracts. Under most conditions, unions reject an efficient contract and are more likely to choose an implicit contract, but a type of contract new to the economic literature could predominate over either.     

Thinking About the Emotional Interaction of Therapist and Family

The emotional interaction of therapist and family has been difficult to explore within the field of systemic family therapy. This paper looks at ways of thinking about this process. As a starting point, I take some feelings I had with three families in the course of therapy. These are used to illustrate some concepts from analytic therapy which address the emotional interaction of therapist and family. The kind of theoretical space and guidance offered within systemic family therapy is then explored, and it seems that the Milan frame gives some space for thinking about the process but offers little guidance as to exactly how this might be done. This is a paper about practice, though it's primarily a theoretical discussion. There is no aim of establishing a ‘correct’ way of understanding the emotional interaction of therapist and family.