Screen time: Clinical notes regarding Meissner's (2006) chronically late patient.

This communication is a commentary on William W. Meissner's presentation (see record 2006-20697-003) of a patient who chronically came late for sessions. The time duration of analytic work-relatively restricted per hour yet potentially limitless in overall duration-represents an existential paradox that is fundamental to the basic representational qualities of mental experience, and inherent in a mute way in the analytic frame. It is to be expected that the latent temporal elements of the patient's conflicts will inevitably challenge this aspect of the frame, subtly coercing patient and analyst to recreate these novel dimensions. If the analyst is too cautious regarding the inevitability of countertransference reactions to such a patient, important developmental opportunities may be missed. I suspect that the chronic lateness and absence that characterized the work with this patient screened an early, nonmentalized trauma that had torn a hole in the foundations of the patient's sense of time, and was inadvertently expressed by Meissner in an entirely atypical manner. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Screen time: Clinical notes regarding Meissner's (2006) chronically late patient: Reply to commentary by M. H. Spero.

Responds to the comments made by Moshe Halevi Spero (see record 2008-00996-014) on the current author's original article, Time on my hands: The dilemma of the chronically late patient (see record 2006-20697-003). First of all, I would like to express my gratitude to Professor Spero for his thoughtful, penetrating and thought-provoking commentary on my chronically late patient. Whenever one's efforts elicit such a sensitive and probing reflection, the effect can hardly be anything but gratifying. Spero's reflection brings to bear a deconstructive perspective that effectively captures the uncertainty, ambiguities, and conflicting pressures created in an analytic process that had become abbreviated, fragmented, diffused, frustrated, and constantly hovering seemingly on the brink of disruption. His approach thoughtfully probes the periphery and penumbra of significance surrounding the playing out of events in this analytic process, and his inquiry thus brings into focus a number of salient issues that could not be engaged or whose meaning could not be effectively ascertained because of the dissolute quality of the analytic effort. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

"How anti-gay bias compromised a treatment: A commentary on Meissner (2006)": Reply.

Responds to the comments made by Michael C. Singer (see record 2008-00996-012) on the current author's original article, "Time on my hands: The dilemma of the chronically late patient" (see record 2006-20697-003). The current author states "I am grateful to Dr. Singer for his interest and stringent criticism. However, in reading his commentary I had the odd feeling that I was being caustically attacked for views expressed in an article I did not write. However, perhaps the deficiency is mine in that my expression failed to achieve an adequate level of clarity and precision." The author regrets that he could not write an article to suit Dr. Singer's tastes, and that in the article he did write there were unavoidable gaps and deficiencies in the material because of the time constraints and distortions in the analysis. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

How anti-gay bias compromised a treatment: A commentary on Meissner (2006).

Comments on the original article, Time on my hands: The dilemma of the chronically late patient by W. W. Meissner (see record 2006-20697-003). Meissner's paper purports to examine a chronically late patient. What emerges instead is an example of antigay analytic bias that is rarely acknowledged in this era of increasing acceptance of nonheterosexual orientation. Fr. Meissner described his use of coercive interpretations and collusion with the patient to suppress unwanted expressions of and activities around sexual orientation. This commentary briefly recapitulates the recent history of psychoanalysis' awakening over issues of sexual orientation and attempts by the profession's major figures to expand their understanding of human sexuality. The opportunity to reexamine an historical homophobic stance is used in this commentary to produce a more parsimonious interpretation of the patient's chronic lateness and other issues around contamination of the treatment by antigay analytic bias. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The therapeutic alliance--a proteus in disguise.

The therapeutic alliance is a vital component of not only the psychoanalytic relation but of all therapeutic encounters between psychotherapist and patient. Despite the universal application and realization of the alliance concept in therapeutic endeavors, it is often ignored as an operative concept in the therapeutic theoretical armamentarium or is formulated in alternative terms. It also comes into play implicitly, even when the concept is formally dismissed as irrelevant. This discussion addresses the meaning and variations of expression of the alliance in the clinical setting and focuses particularly on ways in which the alliance is actually formulated in alternate terms that usually address some partial aspect of the alliance without acknowledging its relevance or importance in the therapeutic relationship and interaction between therapist and patient. I conclude that even when its role in therapy is ignored, minimized, or denied, the alliance continues to play a vital role that requires therapeutic attention and processing in its own right. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Therapeutic alliance: Theme and variations.

The therapeutic alliance is often misconceived, misunderstood, or ignored in conceptualizing the therapeutic process and the therapeutic relation in analysis and other forms of therapy. Conversely, I will argue that the alliance is indispensable in all forms of therapy. After briefly outlining the nature of the alliance, I discuss some of the empirical findings regarding its utility in various therapeutic contexts. I then consider its role and function in various therapeutic settings other than adult analysis and psychotherapy, including child analysis, treating various forms of psychopathology, and related contexts like supervision, forensic psychiatry, and hospital and medical treatment. The alliance plays a definite but analogous role in all of these, with differences according to context. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Clinical implications of research on brief dynamic psychotherapy II. How the therapist helps or hinders therapeutic progress.

In this second of a two-part article, we describe how the therapist's interpretations promote therapeutic progress. Any therapist behavior that is in accord with the patient's plan will be helpful to the patient, but interventions that are at cross purposes with the patient's plan will not be helpful. The implications of the plan concept for brief dynamic therapy are described and contrasted with other key technical, concepts such as transference interpretations, therapeutic alliance, and interpretive activity. The importance of understanding the patient's plan and intervening in accord with it are illustrated in several case vignettes. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Endangered by interpretations: Treatment by attitude of the narcissistically vulnerable patient.

Some narcissistically impaired patients present a particularly difficult therapeutic challenge. They often cannot tolerate interpretations because they view interpretations as humiliating evidence that they are shamefully defective. For these patients, "treatment by attitude" and without significant interpretation may be the only way they can feel safe enough to allow the therapeutic process to unfold. Two cases are discussed. In the 1st case, the usual therapeutic attitude of nonjudgmental acceptance was sufficient. The 2nd case was counterintuitive because the patient needed the therapist to demonstrate a complete lack of worry about the patient for her to make progress. Although the therapist's attitude is part of every treatment, it may be particularly important in the treatment of more severely disordered patients. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The role of transference work, the therapeutic alliance, and their interaction in reducing interpersonal problems among psychotherapy patients with Cluster C personality disorders.

The aim of the present study was to examine whether transference work, the therapeutic alliance, and their interaction predicted a reduction in interpersonal problems at treatment termination. Forty-nine patients with Cluster C personality disorders from a randomized controlled trial investigating the effectiveness of short-term dynamic psychotherapy and cognitive therapy were included. Transference work was measured with the Inventory of Therapeutic Strategies (Gaston & Ring, 1992), while the therapeutic alliance was measured with the Helping Alliance Questionnaire (Luborsky, Crits-Christoph, Alexander, Margolis & Cohen, 1983). Less emphasis on transference work predicted overall reduced interpersonal problems, whereas the effects of the therapeutic alliance did not reach statistical significance. An interaction effect was also demonstrated, indicating that greater emphasis on transference work performed on patients with lower therapeutic alliance ratings was associated with a smaller reduction in interpersonal problems at termination. However, the results also indicate that a low dose of transference work may be beneficial in reducing interpersonal problems. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

I apologize for being late: The courteous psychotherapist.

Psychotherapists may behave discourteously toward clients, often unconsciously and without being aware of it. The effort here is to alert therapists to the simplest ingredient of the positive therapeutic relationship--behaving courteously toward our clients. A limited number of pitfalls are discussed including: tardiness, tiredness and fatigue, in-session electronic interruptions, drinking alone in the presence of the client, checking the clock, and improperly addressing clients by name. This brief list encourages therapists to be alert to these as well as other behaviors that may have the potential to be offensive. When therapist discourteous behavior has taken place, it is important for therapists to do what they can to repair the damage, especially if a rupture has ensued. It is recommended that therapists encourage clients to discuss their feelings about the offending behavior in the presence of the nondefensive therapist. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The role of relationship and technique in therapeutic change.

This article discusses varying perspectives on the role of technique and the relationship in therapeutic change. The theoretical assumptions underlying the debate are briefly described, as are the positions of humanistic, behavioral, psychodynamic, and experiential orientations. Theory and research that consider the integration of relationship and technique are presented. It is then proposed that there are general principles of therapeutic change that are facilitated by both the relationship and technique. It is suggested that these principles of change should be seen as the active ingredients of therapy, thereby moving the field away from a debate about whether technique or the relationship is more important. Instead, an emphasis on studying general principles of change and the processes by which technique and relationship facilitate these principles is encouraged. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The real relationship in psychotherapy: Relationships to adult attachments, working alliance, transference, and therapy outcome.

The purpose of this study was to understand how the real relationship (RR) relates to important process and outcome variables from both the clients’ and therapists’ perspectives. Using a sample of 31 therapist/client dyads at a university counseling center, the authors examined the RR at the 3rd session of therapy and at termination. The results revealed that client adult attachment avoidance was negatively correlated with client RR, while client adult attachment anxiety was uncorrelated. Therapists’ ratings of negative transference were negatively correlated with therapist-rated RR and were uncorrelated with client-rated RR. Hierarchical linear modeling analyses were conducted to predict postintervention outcome from client and therapist perceptions of the RR. Therapists’ ratings of the RR accounted for a significant amount of variance in client posttreatment symptoms while controlling pretreatment symptoms. Client-rated RR total scores and client and therapist 3rd-session alliance scores were not significant predictors of postsymptom ratings. Implications of the usefulness of measuring the RR in psychotherapy are discussed, as are recommendations for future study. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Focus on therapeutic alliance: The psychometric properties of six measures across three treatments.

The psychometric properties of six measures of therapeutic alliance (California Psychotherapy Alliance Scales; Penn Helping Alliance Rating Scale; Vanderbilt Therapeutic Alliance Scale; and the Working Alliance Inventory- therapist, client, and rater versions) were compared in a sample of 60 substance-dependent individuals participating in a randomized clinical trial of three psychotherapies. Internal consistency, interrater reliability, and intercorrelations among the instruments were evaluated. Results supported the construct validity of the therapeutic alliance and indicated that all six measures had acceptable reliabilities. Correlations between observer and participant measures were comparatively low. Reliabilities did vary, however, by treatment condition, suggesting that psychometric properties, and by extension alliance-process-outcome relationships, may vary across treatments. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Intersubjective observations on transference love.

In this article, the clinical phenomenon of transference love is used to make 3 contributions: (a) to illustrate how the intersubjective field can encompass more than just patient and therapist, (b) to provide an intersubjective framework for understanding transference love, and (c) to demonstrate how selfobject and antidote functions of the therapeutic relationship can alternate within the same patient–therapist dyad as figure and ground. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Review of The analysis of the transference in the here and now and Essential papers on transference analysis.

Reviews the books, The analysis of the transference in the here and now by Gregory Bauer (see record 1994-97149-000) and Essential papers on transference analysis, also by Gregory Bauer (see record 1994-97131-000). These are companion volumes which present an excellent, systematic understanding of Bauer's contemporary approach to Here and Now Transference Analysis in psychodynamic and psychoanalytic practice. The here-and-now method highlights the use of the affective immediacy of the relationship between the patient and therapist to "clarify, explore and modify interpersonal conflict rather than as a springboard for discussing the genetic determinants of conflict." Bauer focuses on reactions and behavior patterns that are transference based, as opposed to focusing on the transference neurosis seen as the systematic development and interpretation of fantasies and attitudes that are highly organized and displaced onto the therapist. The former is viewed as a less intense variation of the latter; both are felt to be a part of the same transference continuum. Bauer's volumes provide the clinician with an excellent overview and primer on Here and Now transference analysis, as well as its history, conceptual underpinnings and techniques for using it in the therapeutic relationship. The analytic and psychodynamic practitioner alike will find these books an invaluable addition to their professional libraries. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The therapeutic alliance and family psychoeducation in the treatment of schizophrenia: An exploratory prospective change process study.

Although family psychoeducation has been shown to be highly efficacious in the treatment of schizophrenia, the mechanisms underlying the treatment's success are poorly understood. The therapeutic alliance in behavioral family management (BFM) was examined to determine whether the alliance plays a role in the efficacy of this treatment. One early BFM session (mean session = 6.5) involving 28 schizophrenia patients and their relatives who participated in the National Institute of Mental Health's Treatment Strategies in Schizophrenia study was coded using the System for Observing Family Therapy Alliances. Results indicated that when relatives developed a positive therapeutic alliance, patients were less likely to show prodromal signs of relapse and be rehospitalized over a 2-year follow-up period. When patients developed a positive alliance, relatives became less rejecting and were less likely to feel burdened over a 2-year period. The data suggest that the development of a positive therapeutic alliance within family psychoeducation may play an important role in preventing the escalation of psychotic symptoms and improving family relationships. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The relationship among patient contemplation, early alliance, and continuation in psychotherapy.

The present study examined the relationship among contemplation stage of readiness to change, formation of an early therapeutic alliance, and psychological distress following the first session of psychotherapy. Significant correlations between the contemplation scores and the therapeutic alliance were found for patients in the contemplation stage. Although contemplation scores were not a factor in return for a second session of psychotherapy, the bond subscale of the alliance inventory did significantly contribute to whether patients returned for therapy. Patient psychological distress was not a significant factor in predicting the early alliance. Results indicate a need for further focus on contemplation with its inherent ambivalence, its relationship to alliance, and continuation in early psychotherapy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Effects of structured clinician training on patient and therapist perspectives of alliance early in psychotherapy.

This study investigates the effects of structured clinician training in a Therapeutic Model of Assessment (TMA) and Short-Term Psychodynamic Psychotherapy (STPP) on therapeutic alliance variables measured early in treatment. Thirty-four outpatients received psychotherapy from clinicians who had undergone structured training in a TMA and STPP. A 2nd group of 34 outpatients were assessed using a standard model of assessment and received general, nonstructured training in psychodynamic-eclectic treatment. Groups were matched on key demographic and clinical variables. Results demonstrated significant differences between the 2 groups on both patient- and therapist-rated alliance variables, with higher scores from those in the structured clinical training group. The impact that structured training and supervision may have on graduate clinicians' ability to form positive collaborative relationships with their patients is discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Processes involved in client-nominated relationship building incidents: Client attachment, attachment to therapist, and session impact.

Thirty volunteer clients of trainee therapists nominated an incident that was critical in the development of their therapeutic relationship. Clients completed the Client Attachment to Therapist Scale (CATS), the Experiences in Close Relationships Scale (ECRS), and the Session Impacts Scale (SIS). Clients reported an increase in attachment security with their therapists, along with perceptions of support and relief and increasing exploration following the relationship building incident. While clients' avoidant attachment was unrelated to attachment to the therapist prior to the incidents, in subsequent sessions avoidance was related to a change in secure attachment to therapist. Finally, client attachment to therapist but not general attachment was significantly related to in-session exploration. Findings are discussed in light of attachment theory and convergence with findings from the field of social psychology. (PsycINFO Database Record (c) 2010 APA, all rights reserved)