Considering characterological resistances in the psychotherapy supervisor

The characterological resistance of the psychotherapy supervisor to engage in authentic relatedness with psychotherapy supervisees is examined. Three types of supervisor resistances are considered: Autonomy based, shame based, and narcissism based. These resistances are placed within a developmental context and are viewed as particularly problematic for supervisors new to the role of supervising. While these resistances can subside over time, they still have a decidedly negative impact on the supervision experience and can restrain supervisee learning and growth as a therapist. Self-analysis, psychotherapy, psychotherapy supervision coursework, and the supervision of supervision are presented as methods by which supervisor characterological resistances can be attacked.     

Interaction in the Kleinian and Interpersonal Traditions

Shame is briefly described in terms of affective experience, its signal qualities, and its role as trigger and response to characterological defenses. While patient shame has been elaborated in recent years, the analyst's shame has been less considered. Since shame is so contagious a noxious emotion, exploration of patient shame inevitably evokes shame in the therapist. Sources of analyst/therapist shame are assessed in this paper, including countertransference reactions, convictions of inefficacy in the therapeutic endeavor; and responses to patients' non-mutually determined termination. Broader patterns of analyst shame are examined with regard to the training institution (e.g., training analyst status, referral patterns); the broader community (e.g., the role of dynamic psychotherapy in the pantheon of psychological and medical treatment); and personal factors (e.g., aging and illness). A perspective is offered on these subjective shaming assaults.     

Understanding what is hidden. Shame in sexual abuse

Competence in treating the victims of sexual abuse and exploitation requires an understanding of shame, the complex and multilayered emotion triggered when we have been exposed or when our self-esteem has been reduced. The experience of shame is initially physiologic, involving a cortical shock momentarily halting higher cognitive function, but followed immediately by a host of associations to previous experiences of shame. Acutely, the affect itself impels hiding, while defenses against it include anger, humor, silence, and a wide range of behaviors. In our culture, all sexuality involves an interplay between exposure and privacy, between control and release. The sexual abuse of adults and the sexual exploitation of children must produce shame, study of the interaction between abuser and abused suggests that shame conflict figures prominently in the genesis of such activity. To the extent that psychotherapy itself involves exposure, it must trigger shame; thus, it is likely that the therapist unskilled in the recognition of shame in all its disguises will overlook or misunderstand many of the issues that should form the core of our treatment of those whose sexual selves have been abused or exploited.     

Affective Indicators of the Psychotherapeutic Process: An Empirical Case Study

By analyzing facial expressions of emotion and the emotional experience of a patient and a psychotherapist, we attempted to objectively register unconscious interaction processes that could have contributed to the failure of a psychotherapy that ended prematurely. In this connection, the affect ‘contempt’ played a particular role. It is made clear how an unconscious enactment results in a gap between emotional expression and experience. In addition, the countertransference of the psychotherapist is examined and the emotional experience is contrasted with her affective behavior. In this study, it is demonstrated how this particular psychotherapy failed due to a lack of acknowledging the involvement of the interactive dynamics.     

Common psychological defenses seen in the treatment of sexually abused adolescents

The negative psychological aftermath of sexual abuse is complex and has a direct correlation with the establishment of maladaptive defense mechanisms. Long-term psychotherapy can allow the adolescent patient to establish the cognitive and affective connections to the original trauma and work through the residue of guilt and shame. As mastery is achieved through the treatment process, higher level defenses should become more pronounced. Because the repressed memories related to the sexual trauma need to be unfolded slowly, so that the defensive capacities are not overwhelmed, treatment may need to be continued into adulthood. This paper proposes a theoretical discussion to assess the psychological defenses commonly seen in adolescents with a history of sexual abuse. Further research is needed on the sexually abused patient's intrapsychic experience and the development of defenses used to ward off painful memories related to the sexual trauma.     

Origins of dialogue: phenomenological theories of intersubjectivity in developmental perspectives and as a foundation of psychotherapeutic processes

Recognizing the other with his/her psychic peculiarity is an important assumption for psychotherapy. But how is empathy possible? Answers are to be expected by phenomenological-philosophical approaches concerning intersubjectivity and infant research. They are described in a comprehensive way and related to each other in spite of their epistemological differences. As can be seen in the beginning of showing and reading maternal emotions (so-called "social referencing") an infant is able to show intersubjective behaviour from the age of nine months on. Research on the reflected image of the infant and the development of shame shows that consciousness of the ego is not built before the age of one and a half years. These empirically well established results contradict those phenomenological approaches claiming that the other cannot be experienced directly but via cognitive analogies of own emotions (Lipps, Husserl). They better fit an anthropology that states the human being as an innate dialogically structured one and therefore being capable of empathy. Therefore the base for a deeper understanding of the following results of psychotherapy-research is established: 1. Early infant's memories probably do not exist as isolated images but are embedded in interactional structures. 2. Strict therapeutical abstinence may be experienced as a denial of communication and may have a retraumatic effect. 3. Quality of therapeutical relationship is crucial for the success of psychotherapy.     

Group psychotherapy with obese disordered-eating adults with body-image disturbances: an integrated model

Body-image disturbances and body-image misperceptions are common phenomena in the adult obese or disordered eating population, but they have received scant notice in group psychotherapy literature. This paper integrates an important missing conceptual link of body-image development and offers a group psychotherapy treatment model. This paper does not address the eating disorders, i.e., bulimia and anorexia nervosa. The integrated concept described here will show how a group psychotherapy model can effectively treat body image disturbances which often stem from developmental deficits. It also addresses problems with those patients, who, after weight loss, continue to have misperceptions of their size and shape, and experience shame and self-loathing as a result.     

Facial expression and experience of emotions in psychodynamic interviews with patients suffering from a pain disorder. Indicators of disorders in self- and relationship regulation in the involuntaryfacial expression of emotions

In clinical practice, it is often difficult to establish a positive relationship with patients suffering from psychogenic pain disorder. The present study addresses this maladaptive relationship pattern that is characterized by a mixture of disappointment and rejection. Facial expressions of emotions of 21 female patients in psychodynamic interviews were analyzed and compared to a control group of 11 healthy subjects. The assumption of a maladaptive relationship pattern is supported by an increase in negative facial expressions, especially contempt, on the side of the patients and the interviewer. These negative emotions indicate a disorder of self- and relationship regulation and are negatively correlated with the level of structural personality organization (as measured by the operationalized psychodynamic diagnostic). They also correlate with the emotional experience of shame and fear and are negatively correlated with the experience of joy. The results demonstrate how maladaptive relationship patterns are implemented at the level of involuntary emotional behavior. They can help to understand and improve the emotional quality of therapeutic relationships.     

Metaphor and psychotherapy.

The authors describe the role of metaphor in the theory and practice of psychotherapy. Metaphors are considered fundamental elements of our worlds of language and concepts and not just figures of speech, poetic devices, parables, or creative ways to make interpretations. Metaphors shape the process of therapy by structuring the therapist's perceptions, stance, and attitude. They also organize the way problems are discussed as well as the solution that are seen as effective. The authors review the literature on metaphor in psychotherapy and explore common psychotherapeutic metaphors such as "psychotherapy is war," "the mind is a brittle object," "the conduit metaphor," and a variety of somatic metaphors. They conclude with a discussion of how metaphors function in the process of psychotherapy.     

The role of shame in post-traumatic stress disorder.

Shame is an important part of human experience but, by its very nature, is often neglected as an issue in treatment. Various recent conceptions of shame and its place in personality development, interpersonal relationships, and psychotherapy are presented. The contributions of affect theory are explored in their applications to the understanding of post-traumatic stress disorder, and implications for treatment are discussed.     

Cognitive and emotional conflict in anorexia: reanalysis of a classic case

This paper outlines a theory of the causation of anorexia. Extending Lewis's work on shame, I propose that anorexia involves an interminable quarrel between patient and family. This quarrel is caused by unacknowledged shame, leading to chain reactions of emotion, sequences of shame and rage. To illustrate, I use an earlier case study, a microanalysis of dialogue in a psychotherapy session. This study provided an analysis of the cognitive structure of the quarrel but not of the emotional structure. The proposed theory complements and extends the earlier study, and suggests a treatment rationale and method.     

Group psychotherapy with older adults

This article describes a psychodynamically oriented psychotherapy group for older adults conducted in an agency setting, highlighting the problems specific to such groups. The literature on such groups for older adults is reviewed. The issues discussed are the psychology of late life, diagnostic considerations, medical illness and dementia as complicating factors, the issue of caretaking, and the centrality of shame. A systems-oriented approach to understanding the group's success is suggested.     

The relationship among shame, guilt, and self-efficacy

The perception of the self has been one of the fundamental constructs in psychotherapy, with attention devoted to shame, guilt, and, more recently, one's perception of ability to influence a situation-that is, self-efficacy; however, the relationship between these constructs merits scholarly attention. In the present study, researchers analyze the survey responses of 194 college students to determine relationships between shame and guilt as measured by the Test of Self-Conscious Affect (TOSCA 3, Tangney & Dearing, 2002), and self-efficacy as measured by the general and social self-efficacy scales (by Sherer, Maddux, Mercandante, Prentice-Dunn, Jacobs, & Rogers, 1982). Results support a hypothesis that higher shame scores were related to reduced self-efficacy; however, scores did not reveal a significant correlation between guilt and self-efficacy. Post-hoc analyses suggest some differences based on gender and private-versus-public school setting. The researchers draw theoretical and counseling implications from the findings.     

Can legislation provide a better match between demand and supply in psychotherapy?

BACKGROUND: There is evidence showing that psychotherapy very often does not reach the persons most in need of it. A change in patterns of "consumer behaviour" is difficult to achieve on the basis of individual behavioural change. Can it be achieved by changes in legislation? METHODS: By comparing socio-demographic criteria of patients seen at the University Clinic of Psychoanalysis and Psychotherapy between 1990 and 1996, we are able to give some evidence that changes in legislation, concerning psychotherapy, which took place in the years 1991, 1994 and 1995, had a significant effect on the socio-demographic composition of our patient population, showing a convergence of patient population towards the socio-demographic criteria of the population of Vienna. CONCLUSION: We argue that the changes in legislation in Austria, concerning funding of psychotherapy, and introducing a new profession "psychotherapist", have a measurable effect which works in two ways: 1) direct effect: decreased financial charge of patients; 2) indirect effect: increased motivation of patients, resulting from a reduction in stigmas attached to the role of "psychiatric patient".     

Barriers to care-seeking for depressed African Americans

OBJECTIVE: We explored perceived barriers to mental health care-seeking for depressed, low-income African Americans who are already engaged in psychotherapy. METHODS: During a trial to improve psychotherapy appointment adherence, we asked all African-American participants, "Research shows African Americans with emotional or psychological problems use mental health services at half the rate of whites with similar problems. Why do you think that is?" Responses were captured verbatim. RESULTS: Of 53 African Americans enrolled, 43 completed the study. We analyzed their responses in the hope of identifying modifiable responses. We used qualitative analytic methods, with four raters achieving consensus in coding responses into 13 thematic categories. Stigma was the most frequent response, followed by dysfunctional coping behavior, shame, denial, and "don't know." CONCLUSION: While this study supports several barriers to care-seeking reported in the extant literature, our data also underscores the prominence of shame and denial, together with their complex interrelationships to public stigma and depression, respectively. Future research should assess the relationships between these factors to mental health care-seeking behavior in low-income African Americans and ways of modifying them.     

Who is the Dreamer Who Dreams the Dream and Who is the Dreamer Who Understands It

Sandra Buechler has made a very important contribution to our understanding of the role psychoanalytic training can play in the generation and deepening of shame in psychoanalytic candidates. Unfortunately, it is inevitable that this culture of shame will come to include our patients unless we become more aware of humiliation processes in training. Likewise. Andrew Morrison again movingly describes for us the personal experience of shame. My contribution is to contextualize shame, and to argue that while shame may be experienced individually, it is a relational and systemic phenomenon in its genesis, maintenance, and consequences.     

Psychosocial and psychosomatic medicine as well as psychotherapy in Switzerland -- developments over the past fifty years

The development of psychosocial and psychosomatic medicine in Switzerland is as diverse as the country itself with its four official languages and 26 cantons. Psychosomatic medicine of the past and present can be seen in three phases: Psychogenesis of somatic diseases ( phase 1: from about 1930-1960), bio-psycho-social medicine (phase 2: from 1960-1990) and psychobiology in medicine (phase 3: since 1990). In Switzerland the first phase scarcely noticeable, whereas active development in all fields of psychosomatic medicine and psychotherapy has taken place since 1960. The main tendencies of this development are described. The current situation for patients with psychosomatic and somatopsychic disorders is quite good in the outpatient setting. For inpatient treatment there are only about 400 beds in 19 small departments for the whole country. The strengths of the psychosomatic service system are well-established cooperation of doctors and psychotherapists and only few reactions by health insurance companies. Weaknesses are too few inpatient treatment facilities with long waiting times for patients and a lack of specialized treatment for migrants with psychosomatic disorders. Future prospects are not rosy due to the financial situation in the healthcare system, but neither are they bleak, since patients are emphatically asking for more narrative-based medicine and a partnership-based doctor-patient relationship.     

The meaning bearing other--a relational view of the child psychotherapeutic process

With child psychotherapy as the point of departure, meaning making in therapy may be described in light of the patient's relationship to the psychotherapist as "a meaning bearing other"-that is, someone who allows the possibility of meaningful thoughts and feelings, either through his or her actual communicative presence or as an unconsciously imagined communication partner. Within the theoretical framework of this article, being with a meaning bearing other is regarded as a prerequisite for development of both immediate, playful and reflective understanding of needs, wishes, and affect in self and other. The term meaning bearing other refers to three distinct but often synchronic modes of relatedness. These may be seen as developmental imperatives in both parenting and psychotherapy. The present article is a theoretical and clinical inquiry into the prerequisites for change in relationally oriented psychoanalytic psychotherapy. The article discusses what might be seen as basic forms of relatedness and interaction in light of Winnicott's developmental approach, relational and neo-Kleinian approaches within psychoanalysis, and also Heidegger and Gadamer's philosophy of meaning and interaction. The theoretical points of view are illuminated and illustrated through an excerpt from the first session from a twice-a-week psychotherapy with a 5-year old boy.     

Reflections on psychodynamic psychotherapy supervision for psychiatrists in clinical practice

Much has been written about psychotherapy supervision for trainees in psychiatry. Psychiatrists are also encouraged to receive supervision when dealing with difficult patients or when involved in personal events that have the potential to have an impact on their psychotherapeutic work. Nevertheless, a literature search, conducted through Medline, revealed few publications dealing with supervision of psychiatrists who conduct psychotherapy in clinical settings after completion of training. This article discusses the issues involved in psychotherapy supervision for the supervisor, supervised psychiatrists, and their practice settings and patients. The author first discusses the benefits of psychotherapy supervision for psychiatrists in clinical practice, including helping psychiatrists maintain and improve psychotherapeutic skills, assistance in dealing with patients who have complex or especially challenging problems (e.g., personality disorders, intractable depression, difficulties with compliance, complex psychosocial problems), addressing ethical concerns, boundary issues, and transference and countertransference, and helping psychiatrists deal with personal issues that may cause difficulties in providing psychotherapy or issues that arise in working with a multidisciplinary team. The author then reviews key issues related to the supervisory process, including group versus individual supervision, the role of the supervisor, different supervisory styles, and factors that can contribute to feelings of shame or vulnerability in the supervisee. The author also discusses different supervisory styles, clarifies the distinction between therapy and supervision, and discusses issues that arise in the supervision of experienced psychodynamic therapists. Barriers that may keep psychiatrists from seeking psychotherapy supervision are reviewed. Finally the author discusses the supervision of those acting as supervisors for other clinicians.     

'Evidence-based medicine' in the Dutch and Flemish psychiatric, psychological and psychotherapeutic specialist literature: widely used?

The expression 'evidence-based medicine' was first used in medical journals in the 1990's. Recent research has shown that the expression appears very frequently in international medical publications. Until recently, however, there were no research data concerning the frequency with which the expression is used in the titles and summaries in Dutch and Flemish specialist journals in the field of psychiatry, psychology and psychotherapy. In our systematic review of the Dutch and Flemish specialist medical literature published between 1990 and 2003 we found that the use of the expression increased markedly as from 1997.