Psychotherapy, Suggestion and Sexuality: Historical and Epistemological Considerations

ABSTRACT. This paper explores the reasons for the resistance against investigation of the close affective ties which arise between patient and therapist in psychotherapy. It holds that a confusion between attachment and sexuality may be one reason why psychoanalysts do not study the role of suggestion - defined as an archaic, preverbal affective relationship -in psychotherapy. While American writers have investigated the question of sexual relations between therapist and patient, ever since the advent of animal magnetism 200 years ago provoked fears of erotic involvement, the deep affective sources of change in psychotherapy have been masked by the taboos of sexuality.     

THE WEBSITE'GIRL': CONTEMPORARY THEORIES ABOUT MALE'FEMININITY'

ABSTRACT I explore a bisexual male patient's need to differentiate highly problematic'feminine'identifications - originating in childhood sexual abuse and impingement by men as well as women - from identifications with more admired aspects of his mother. My main focus is on the patient's sexual identity - the personal meaning he gave to being male - rather than on his bisexuality - his desire for both sexes. In psychoanalytic literature powerful opposite-sex identifications are usually associated either with psychotic confusion or celebrated as a source of psychic strength. The co-existence of problematic and highly valued cross-sex identifications is rarely discussed. I also look at how this patient re-negotiated his identity through the transference relationship with a female psychotherapist, given that his'masculinity'derived mainly from childhood experiences of 'stealing'his mother's phallic power. Through a wideranging theoretical review I conclude that we need to draw together opposing psychoanalytic perspectives about maternal and paternal power, opening up new ways of thinking about triangular relationships in the transference.     

Psychodynamic Psychotherapy,Insight, and Therapeutic Action

It has often been observed that, in general, different psychotherapies do equally well. Some have taken this as good evidence that therapeutic action in psychotherapy rests not on the factors specific to individual therapies, but on common factors. I argue against this view in favor of a theory of therapeutic action deriving from psychodynamic psychotherapy. This identifies the therapeutic relationship (and with it, many so‐called common factors) and “psychodynamic insight” as therapeutic factors. I review the evidence from outcome studies and from studies into two concepts related to insight, specifically reflection function and psychological defense. I argue that the best interpretation of the evidence supports the claim that insight, in interrelation with the therapeutic relationship, contributes to therapeutic action.     

Are Psychotherapists Out of Touch?

ABSTRACT. Touching - as well as not touching - conveys messages- It also constitutes aprimary experience with emotional and trophic effect Both functions arc important for psychotherapy.
Attachment theory logically implies (and experience confirms) that patients who lacked adequate mothering in early life require - like children - actual physical cam-giving. It may he necessary to communicate with some patients by touch before treatment can start, whereas others are at first afraid to be touched. However, an essential pan of psychotherapy is enabling patients to lose their fear of accepting what they need.
Objections m therapeutic touching are subjective and due largely to sexual fears. Problems in this area emphasise the imperative need for all psychotherapists to have regular access to therapeutic supervision.     

The Harmful Effects of Psychotherapy: When the Therapeutic Alliance Fails

A good therapeutic alliance has been found to be the best predictor of outcome in psychotherapy, but psychotherapists also need to develop an understanding of the mechanisms by which that alliance is created and the factors that may damage that alliance and contribute to harmful effects of psychotherapy. I explore these factors in three contexts: the nature of the therapy itself, the characteristics of the therapist, and the dynamics of the patient–therapist relationship. I discuss the research that suggests that potentially harmful processes can be avoided by a dynamic‐agentive systems model, which views psychotherapy as a conversation, in which turn‐taking, rupture and repair, and perspective‐taking are the intersubjective tools that help to build the therapeutic alliance and that can be the focus for further study into the mechanisms by which psychotherapy is helpful or harmful. The neuroscience research that supports this model is summarized.     

Being,having, and becoming bodies

Following on from my earlier paper ‘Body psychotherapy and social theory,’ and continuing the argument that body psychotherapy has a lot to learn from contemporary social theories of embodiment, I describe what might be called the ‘cutting edge’ of those theories and suggest how this work might be applied to body psychotherapy. The crucial argument is that, although the crude Cartesian split between mind and body is clearly inadequate, it is a mistake to see body psychotherapy as trying simply to close the gap and unify mind and body. The experience of ‘having’ a body is intrinsic to human experience, and a necessary component of ‘becoming’ a body.     

Parameters of marriage in older adults: A review of the literature

Three parameters of marriage and their effects on the marital relationship in older adults are reviewed. Studies evaluating the impact of retirement on the marital relationship indicate that the retirement transition is a “generally positive” experience for older adults who are in good health, have an adequate income, and a history of marital compatibility. Maintenance of this positive transition into retirement seems to be dependent on a balance between temporal structuring, purposive activity, and a continuance of social contacts. Investigations of the impact of illness on the marital relationship indicate that the emotional or physical illness of either spouse can cause disequilibrium in the relationship. Decrements in the health of either spouse yield an adverse effect on marital quality. Additionally, the impact is greater on perceptions of marital happiness for the healthy partner than for the partner who is ill. Studies examining the impact of sexual dysfunction on the marital relationship are lacking. Scarcity of work in this area appears to be due, in part, to prevailing cultural myths that older adults are physically incapable of sex, have no sexual desire, and are physically unattractive. Yet, a few empirical efforts indicate that sexual relations are not only common among elderly persons, but that, particularly in the marital relationship, sexuality becomes an important source of gratification in a world where gratification of any sort is diminishing.     

Object relations assessment predicts outpatients' attrition,early working alliance and psychotherapy process

This study investigated the predictive utility of assessing clients' object relations functioning to prognosticate therapy dropout, quality of the early working alliance and psychotherapy process events reported by clients after their first five sessions. Clients accepting a recruitment invitation were administered the thematic apperception test (TAT) shortly after intake, and those still in treatment three to four sessions later rated the working alliance and psychotherapy process events. Participants were 47 clients beginning psychotherapy with advanced doctoral practicum students at a university-based community-serving training clinic. The Social Cognition and Object Relations Scales (SCORS), an object relations scoring system for TAT stories, was used to assess object relations functioning. The California Psychotherapy Alliance Scales—Patient form measured four dimensions of the alliance. The Therapy Orientation Process Scales, created from the Psychotherapy Process Q-set, measured clients' perceptions of therapy process events as involving relatively more psychodynamic or cognitive behavioural techniques. The SCORS significantly predicted remaining in therapy, client ratings of stronger working alliance and typical therapy process as more psychodynamic than cognitive behavioural. SCORS complexity of representations and capacity for emotional investment in relationships scales were the strongest predictors, especially of the patient commitment facet of the alliance. The findings suggest that (1) beginning psychotherapy with object relations assessment can be useful for treatment planning and (2) the relationship between clients' object relations functioning, working alliance and greater sensitivity to psychodynamic than to cognitive behavioural interventions depends on the aspect of object relations that is being assessed.     

Assessing the Difficulties for British Patients of Caribbean Origin in Being Referred for Psychoanalytical Psychotherapy

SUMMARY. Caribbean origin British patients are often not referred for psychoanalytical psychotherapy. I will be looking here at referral difficulties through a consultation with a young woman who I will call Miss C. A link will be discussed between the child sexual abuse she presented and borderline states and a plea made for a reassessment of notions about suitability for psychotherapy and for psychotherapeutic help.     

Getting our act together: lessons on meaningful psychotherapy research from the philosophy of science

Psychotherapy research should concentrate on building up a scientifically validated, theoretical knowledge base by means of disciplined empirical research. The normal nested relationship between technology, theory, and research has not been the norm in the world of psychotherapy. Psychotherapy researchers should learn from the history of science and concentrate on building basic theory. Investigations into the causal relations underpinning psychotherapy is the best way that research can help us do psychotherapy better. These investigations must conform to the canons of inductive reasoning. Conventional use of clinical data to underwrite psychotherapeutic theory is vulnerable to Grünbaum's critique. A research proposal based on Langs' communicative approach to psychotherapy is presented predicting measurable unconscious responses to brief, time-limited psychotherapy.     

Revisiting Boarding School Syndrome: The Anatomy of Psychological Traumas and Sexual Abuse

The ABC-D of Boarding School Syndrome clarifies the anatomy of the series of psychological traumas and sexual abuses that contribute to what, in 2011, I first classified as Boarding School Syndrome. The premise is that going to boarding school at a young age may inflict emotional injuries with lasting psychological consequences. The purpose here, ten years on, is to elucidate more fully aspects of the trauma embedded in the earlier writings and in the book Boarding School Syndrome. Research over the intervening years has led to developing an understanding of this enduring harm as presented in adult psychotherapy patients. The initials ABC-D refer to the elements that constitute the multiple traumas suffered by the children: abandonment, bereavement, captivity and as a result, for some, disassociation. As a consequence, children may be vulnerable to sexual advances from paedophile adults, school bullies and the confusing, sexually charged, solace found in dormitories with other children. The accumulation of these events may have the long-term effect of distorting intimate relationships and adult sexuality.     

Losing the Internal Oedipal Mother and Loss of Sexual Desire

This paper aims to examine how it might be possible to use psychoanalytic concepts to explore a deeper understanding of the difficulties with conscious and unconscious same gender sexual desires in psychoanalytic psychotherapy. The author explores how the loss of the unconscious oedipal mother can be manifested as a loss of sexual desire in a couple's relationship. The author suggests that the move from what is referred to as the longed‐for state of being in perfect harmony, to a more realistic state of imperfect harmony can bring about the recovery of an unconscious belief that one can possess the oedipal mother. The move from this fantasy state of merger to a more reality‐based relationship can induce feelings of abandonment and loss, particularly of sexual desire. The implications of this for the transference and countertransference, and the conscious and unconscious nature of erotic desires within the therapeutic relationship are considered. The importance of aspects of technique and the need for non‐pathologizing use of concepts to help clinicians more fully explore formulations and therapeutic interventions are examined. While this paper focuses on lesbian relationships, the relevance of the ideas presented here for other gender pairings is explored.     

The natural history of sexual dysfunction in diabetic women. A 6-year follow-up study

The natural history of sexual dysfunction in diabetic women was evaluated in a 6-year prospective study. Fifty type I, insulin-treated diabetic women, aged 26-45 years, were assessed and re-evaluated 6 years later. Measures included psychological, physiological and social parameters. The frequency of sexual dysfunction was similar in 1977 and 1983. Diabetic women did not differ in sexual function from their healthy controls. None of the physiologic measures studied were predictive of sexual function. Six out of 14 women who were sexually dysfunctional in 1977 recovered normal function, some of them in spite of objective evidence of neuropathy. None of the women had been on psychotherapy for their sexual problem. The most important factor in the spontaneous remission rate seemed to be improvement in the overall marital and social situation. The women's acceptance of illness, as judged by the interviewer, and data from the questionnaires concerning psychological distress, were strong predictors of sexual function. Sexual dysfunction in diabetic women is thus an index of psychological adjustment to chronic illness. Family and marital counseling should be routinely offered as part of the medical care of the diabetic patient.     

Walking the tightrope: developing an attachment-based/relational curriculum for trainee psychotherapists

I describe how the Centre for Attachment-based Psychoanalytic Psychotherapy (CAPP) in London has gone about developing an attachment-based/relational curriculum for training psychotherapists. A key problem the training is meant to address is how to maintain a balance between enabling students to absorb research and clinical knowledge of psychological processes at the same time as they learn to maintain the flexibility necessary to address the uniqueness of each individual encounter in the consulting room. I describe the task of the training in terms of a linguistic metaphor: the training needs to ensure that students are theoretically multi-lingual while developing higher levels of fluency in the language of attachment-based/relational psychotherapy. In the pursuit of this approach, my colleagues and I developed a set of ten key propositions - the spine of the relational world - which we felt encapsulated the main theoretical assumptions of attachment-based practice that students need to understand and explore. This has been used to evolve a spiral curriculum, designed to help students engage constructively with the often confusing emotional aspects of clinical work, and with the multiplicity of clinical viewpoints that characterises contemporary psychoanalytic psychotherapy.     

A review of individual psychotherapy outcomes for adult survivors of childhood sexual abuse

This review examines the current literature on individual psychotherapy outcomes with adult survivors of childhood sexual abuse. As compared to the literature on treatment with victims of sexual trauma in adulthood, fewer researchers have explored the field of psychotherapy outcome with this population, particularly with regard to individual treatments. For this reason, a review of psychotherapy outcome for adult survivors of child sexual abuse is needed. This review first presents issues salient to the study of treatment with this population, such as prevalence, short-term impact, and long-term sequelae of childhood sexual trauma. Next, the eight studies that have been published on individual psychotherapy for this population are presented and evaluated according to both efficacy and effectiveness criteria for a methodologically sound study. Last, directions for future research with this population include continued integration of efficacy and effectiveness methodology, use of multi-method/multi-rater assessment data, as well as further investigation of interpersonal variables such as the therapeutic alliance.     

What Do We Mean by ‘Psychodynamic’? A Contribution to the Development of a Model

I hope to make a preliminary contribution to the development of a model that more clearly reformulates the practices of psychoanalytic psychotherapy in a way that recognizes a diversity of analytic practice that I think has been misdescribed - technically and politically - as 'psychodynamic'. The paper firstly considers the question of definition and suggests four identifiable meanings of the term' psychodynamic'. The discussion then reviews a number of core and inextricably connected questions of theory and practice under the following headings: setting and regression, time and frequency, countertransference, creativity and the real relationship, interpretation and pure technique, and the problem of eclecticism. The paper concludes by briefly exploring the parameters of psychodynamic practice in relation to eclecticism in psychotherapy, and makes a plea for a model that is consistent, authentic and ecumenical.     

Attachment and Object Relations in Patients With Narcissistic Personality Disorder: Implications for Therapeutic Process and Outcome

This article presents a therapeutic approach for patients with severe personality disorders, transference‐focused psychotherapy (TFP), a manualized evidence‐based treatment, which integrates contemporary object relations theory with attachment theory and research. Case material is presented from a narcissistic personality disorder (NPD) patient in TFP whose primary presenting problems were in the arena of sexuality and love relations, and whose attachment state of mind showed evidence of oscillation between dismissing and preoccupied mechanisms. Clinical process material is presented to illustrate the tactics and techniques of TFP and how they have been refined for treatment of individuals with NPD. The ways in which conflicts around sexuality and love relations were lived out in the transference is delineated with a focus on the interpretation of devalued and idealized representations of self and others, both of which are key components of the compensatory grandiose self that defensively protects the individual from an underlying sense of vulnerability and imperfection.     

Psychological changes during rehabilitation for newly visually impaired people

In study 1, the purpose was to examine the psychological changes during rehabilitation for newly visually impaired people. Before and after the 6 months rehabilitation training, we conducted Yatabe-Guilford Personality Inventory and Manifest Anxiety Scale (MAS). The results showed that scores of depression, cyclic tendencies, feeling of inferiority, nervousness, lack of objectivity, and anxiety decreased and ascendance increased significantly. In study 2, we compared the differeces of scores between those who needed psychotherapy in addition to rehabilitation training and those who didn't. People who needed psychotherapy scored significantly higher on the depression and lack of objectivity scales than those who didn't. Supportive and behavioral counseling was conducted, however no significant changes were observed before and after psychotherapy as a whole. Furthermore, the relations among the methods, purposes and effects of psychotherapy were not observal. As a conclusion, we need to develop methods of psychotherapy which accelerate the acceptance of disability and improve psychological adaptation sufficiently.     

Therapist–patient sexual involvement: risk factors and consequences

The purpose of the present study was to examine factors that put patients at risk for sexual abuse in psychotherapy and to assess the psychological consequences of therapist–patient sexual involvement. To date, there is a lack of controlled research based on larger samples for both of these controversial issues. In this survey, female patients sexually abused by their psychotherapists (n=57) did not differ from female patients reporting no sexual abuse (n=43), in almost all of the risk factors. However, sexually abused patients had poorer treatment outcomes (p<0.05) and almost all reported negative consequences of therapist–patient sexual involvement. In the regression analyses, only sexual abuse but no risk factor could account for the group differences in the treatment outcomes (p<0.01). Emphasizing therapists' characteristics, future studies need to examine factors of the therapist–patient relationship that increase risk for sexual abuse. Copyright © 2000 John Wiley & Sons, Ltd.     

Prediction of dose-response relations based on patient characteristics.

The recent discussion of evidence-based, adaptive treatment planning highlights the need for models for the prediction of courses of treatment response. We combine a dose-response model with growth curve modeling to determine dose-response relations for well-being, symptoms, and functioning. Hierarchical linear modeling was used to model each patient's expected course of improvement. The resulting predictions were cross-validated on two samples of psychotherapy outpatients. The results give further empirical support for the dose-response model and the phase model of psychotherapy as well as for the usefulness of patient treatment response profiling for individual treatment management.