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Coming and get more than 25 resources of free ebooks. The best free ebook download sites from modern By Cat Ellis T Where id was, there shall ego be" p. Although a contemporary therapist might not be a Freudian at all, he would probably agree that strengthening and expanding that organizing principle often known as the ego have always been important goals of psychotherapy. It is also understood that psychotherapy is aimed at helping the patient with- stand and eventually ignore the primitive demands of a punitive conscience, become more aware of inner and outer realities and their possibilities in many ways, possess better organizing principles, and be able to deal with impulses more productively.
Historically, there has been an evolution in the ways therapists have viewed egostrengthening. In both shamanic and ancient temple healings, for example, the interaction of the afflicted individual with the person of the healer priest was considered to be of the utmost importance Ellenberger, The patient's ego was, presumably, so sufficiently strengthened by his encounter with this magical, powerful parental figure that it could participate in the cure. Varieties of this type of healing relationship persist today e.
We might classify recoveries that spring from such activities as transference cures. In the ancient Asclepian temple healings at Epidaurus, a more sophisticated level of treatment often involved dream interpretation, and memory work, and subsequent rerepression was guided by a priest. The concept of a necessary, special relationship between the patient and the therapisthealer persisted over time; eventually, it became known as rapport, a term still used in hypnosis today.
This should not be surprising because contemporary psychodynamic psychotherapy has its historical foundations in hypnosis. Both Janet, the creator of the theory of dissociation, and Freud, the father of psychoanalysis, practiced clinical hypnosis. Janet identified rapport as a complex phenomenon observed in both hypnotic and nonhypnotic subjects. He believed that it was a necessary gateway for success in therapeutic endeavors.
According to Janet, rapport was characterized by the emergence and flowering of the patient's dependency needs that became focused on the therapist. During the course of the treatment the therapist's task was to help free the patient of his symptoms and guide him to more independent functioning. Like the patient in earlier temple healings, the Janetian patient's ego became strengthened through his identification with a strong and wise parental therapist who would help guide him to greater understandings.
This strengthening allowed him to uncover troublesome material and reassociate it with the rest of his mental content. Unlike the more primitive approaches to healing, this process promoted a gradual weaning of the patient from the healer. During this time the patient presumably relied more on his own ego, which had been strengthened in several ways in the therapeutic encounter.
It appears that the elements of insight and reassociation were additional strengthening elements. However, the greater initiative and strength were still perceived as residing within the healer-therapist. Early in his work with psychological difficulties, Freud, like Janet, believed that trauma caused neuroses to develop; however, he soon abandoned both the trauma theory and hypnosis see chap. His subsequent nonhypnotic theoretical framework, psychoanalysis, with its emphasis on the intrapsychic mechanisms such as repression, eventually displaced Janet's extensive theory of trauma and dissociation Ellenberger, The concept of transference superseded that of rapport in psychotherapy.
Transference is a complex and meaningful affective and behavioral relationship that the patient experiences within therapy. Transference is defined traditionally as a set of perceptions, affects, and behaviors that the patient directs at the therapist.
These perceptions, affects, and behaviors are rooted in the patient's early life experiences with significant figures of authority and superimposed upon the therapist. It was through proper interpretation of the transference and of the patient's resistances to change that insight was able to develop in the analysis.
Transference allows the patient's difficulties to be played out in therapy for the purpose of being understood. Eventually, the patient acquires insight as a result of the analyst's interpretations and is able to change. In psychoanalysis insight is thought of as the mechanism that leads to change.
This a point of view is not universally held by psychodynamic psychotherapists. Some believe that insight actually follows change instead of causing it. This process of analyzing or understanding the transference and other elements of therapy involves collaboration between the analyst and the patient. This idea that the patient might be some sort of partner in psychodynamic treatment has appeared periodically in the literature from the beginning of psychoanalysis. A young Viennese woman named Anna O.
Nevertheless, emphasis on the value of the patient's most mature efforts in the therapeutic process was not a focus of a great deal of attention. With it, the patient's cooperation in achieving certain therapeutic tasks could be enlisted without a struggle.
Freud spoke of the necessity of the analyst's having a "serious interest" in the patient and being able to display "sympathetic understanding. Other analysts also noted the presence of a rational transference Fenichel, or a mature transference Stone, The model used was always authoritarian in tone, however.
The analyst maintained his position as the ultimate sage. When it was present, the patient could carry out the procedures necessary for therapy such as reporting mental content or feeling states. It also allowed the patient to examine and work with unpleasant and regressed material and accept difficult insights.
According to Sterba , the alliance was a manifestation of a temporary and partial identification of the patient with some of the analyst's attitudes, goals, and way of working. This alliance developed because of a split within the patient's ego which produced an observing, or reasonable, ego that could ally itself with the "analyzing ego" of the analyst Sterba, The term therapeutic alliance was coined by Zetzel , who described the patient as having to move back and forth between the transference and a reality-based alliance.
Greenson , had a particular interest in the power of a real relationship that did not depend on transference. This relationship was called the working alliance. Greenson contended "that the working alliance deserves to be considered a full 10 and equal partner to the transference neurosis [in importance] in the patient-therapist relationship" p.
Other conceptualizations of the alliance focus on object relations Bibring, ; Bowlby, ; Gitelson, ; Horwitz, Luborsky , in particular, pointed to the transitional qualities inherent in the therapeutic alliance. According to Hovarth, Gaston, and Luborsky there are pantheoretical models that embrace both interpersonal and intrapsychic aspects of the alliance. They believe that relevant components probably work synergistically.
We refer the reader to the Hovarth et al. Clinical Applications of the TherapeuticAlliance Although the concept of the therapeutic alliance, or working alliance, was developed in psychoanalysis, it has wide applicability throughout many fields of psychotherapy today. It may well represent an evolutionary advance in contemporary psychotherapy because it exemplifies a deliberate attempt to ego-strengthen the patient and activate his inner resources for constructive participation in therapy.
Until it was defined and emphasized, the patient's participation in the therapeutic process was all too frequently relegated to considerations of transference and resistances that emphasized childlike aspects of self. There are many ego-strengthening uses of the therapeutic alliance. As is seen later in this chapter, transference may aid in the development of the alliance, or it may hinder it.
In certain cases a full working alliance can be formed only after the patient's internal psychic structures have become more developmentally advanced as a result of the therapist -patient interaction. Frequently the alliance is a place where patients are able to advance themselves psychosocially E. Erikson, , learning to move into such landmark activities as basic trust, initiative, and cooperation. The Elements of the Therapeutic Alliance There are certain elements that are essential to the development of the therapeutic alliance.
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Some of them come from the therapist, and some from the patient. The emphasis here is on the contributions of the therapist. Although we list them separately, a number of them take place simultaneously. Respect and Interest. It is necessary for the therapist to openly display genuine respect for the patient during the process of history taking and assessment.
Almost all patients, like those who sought the help of healer priests and shamans in the past, possess primitive transference feeling and perceive the therapist as much more powerful and knowledgeable than they. Respect on the part of the therapist can easily move into an interest in how the patient perceives his problems. He also receives important information that will affect his concept of himself. That he has value as a human being, and that his problems, fears, and defenses do not constitute all of who he is.
He had been watching a TV program about schizophrenia, which he called a "split personality," and he concluded that he was a schizophrenic. For some reason we never managed to discuss at the time, he believed that hypnotherapy could help his schizophrenia. I was the closest hypnotherapist he had been able to locate. Jake arrived at his session directly from work; he was dressed in soiled plumber's clothes. His symptom list contained many of the markers for Dissociative Identity Disorder DID , and his early life history was one of incredible deprivation, several varieties of abuse and neglect that began at an early age, and a total lack of stability.
These factors had been compounded by severe dyslexia. Beyond his dyslexia, poor education, and social impoverishment, I saw a very bright young man who was frightened and confused. I was able to give him explanations about schizophrenia and Dissociative Identity Disorder DID that were meaningful to him. He was interested in acquiring this knowledge, and he appeared to feel quite relieved, Jake appeared to have no difficulty understanding my explanations; indeed, he seemed to comprehend them very clearly.
He appeared to be genuine about wanting help. He told me that he was surprised that he had been able to go to a "first session" and more surprised that he had been able to talk so freely.
He told me he wanted to work with me even though he would have to travel a considerable distance and lose money for his time off from his job. His main concern was whether I would find him acceptable as a patient. I told Jake that I had a sense that the two of us could get something done that would be helpful to him if we worked together. As the session drew to a close, Jake asked me whether people who had been abused as children became abusers.
I told him that sometimes it happened, and that was understandable. I did more education with him, explaining the concept of how identification with the aggressor could cause a victim to feel more powerful and in control while seeking a solution for his own abuse through 12 reenactment. Although he had not told me about any inappropriate behavior of his own, clearly there was a possibility that it existed, at the least, in his fantasy life. Jake then was able to tell me that he was frightened that he might abuse some one when he was much older.
When he saw again that I was not judgmental and that I was reinforcing his own perception of his need for treatment, he was able to confide that he was very frightened that he might be molesting someone now and "not even know I'm doing it.
Jake's initial interview illustrates how work on the alliance can be incorporated into the first session. Important elements in this interaction were: Respect Interest Therapist perception that allowed recognition of the patient's motivation and recognition of the patient's intelligence Explicit definition of therapy that included working together An educational model geared to the patient's intellectual and emotional levels Lack of judgmentalism Openness: The therapist did not have all the answers There are other forces that influence the therapeutic alliance in positive ways; one of them is interpersonal safety.
Interpersonal Safefy. The fundamental inclusion of interpersonal safety is crucial to the development of the therapeutic alliance. It is within this context that the therapist is able to strengthen the patient further by providing an understanding of the conditions within which therapy can take place.
The alliance grows stronger as there is comprehension and agreement about issues such as confidentiality, what kind of reporting is legally mandated, the length and frequency of sessions, the fee, cancellation policies, how emergencies will be handled, as well as any other relevant issues. These rules of therapy provide a structure within which the patient may support himself in predictable ways.
Several sessions may be needed to establish these parameters in their initial forms. However, patients maynot come to appreciate some of them, such as boundaries, on a conscious level until much later in treatment.
Case Example: Jake continued Although Jake and I agreed on the frequency of therapy, the length of the sessions, the fee, how cancellations were to be managed, and payment terms, the issue of confidentiality had not been broached. The introduction of the topic of his fears that he might be a current child abuser mandated my responsibility for discussing confidentiality and the limits placed on it by the reporting laws.
Because the material had come up just before the end of the session, I decided not to violate the boundaries of the session time, but to bring these issues up as the first topics to be discussed in the next session. However, if he did not know about the laws, he could well have been planning to confess an act of current molestation of a child in the next session.
In the interests of his personal safety, my putting material about confidentiality and reporting laws on the table would give him choices that would influence his sense of safety and increase his sense of trust.
Consistency is another aspect of structure that frequently provides the patient with ego-strengthening support. The acquisition of sameness in certain parts of our lives often provides a sense of security and releases energy that can be focused elsewhere.
The therapist who is aware of this attempts to put regularity into the patient's situation.
Such things include always giving the patient appointments at the same time and the same place, having the bills come out on the same day of the month, and having some sort of routine for how the sessions proceed e.
Therapy then begins to acquire a rhythm that can feel natural to the patient just as the tides, our revolutions around the sun, or our circadian rhythms do. On each one he grows wiser from his adventures. On the seventh planet, Earth, he encounters a fox, and the little prince invites him to play with him because, at the time, he is unhappy.
Please excuse me," said the little prince.
But, after some thought, he added: "What does that mean tame? And I have no need of you. And you, on your part, have no need of me. To you I am nothing more than a fox like a hundred thousand other foxes, But if you tame me, we shall need each other.
To me you will be unique in all the world. To you I shall be unique in all the world. I shall know the sound of a step that shall be different from all the others. It will call me like music from my burrow. The fox then explains to the little prince that, because of their connection, should it exist, he would always think of the little prince's hair whenever he looked at golden wheat in the fields.
If you want a friend, tame me. When the little prince eventually left to continue his adventures, the fox was sad. However, he explained the great significance of their encounter to the little prince. It has done me good," said the fox, "because of the color of the wheat fields. However, this vignette illustrates the importance of rite and ritual in developing a significant relationship; this can be overlooked in the therapeutic situation.
Like the fox, patients in such positions, like the fox, do eventually feel unique. In this way their egos are strengthened. Its function in therapy is to gain and communicate a greater understanding of the subjectivity of the patient and to bridge the aloneness that he 15 experiences when in the grips of his intense painful feelings. Without empathy there is no true understanding. There is no other quality in the therapeutic situation that can bring greater closeness and intimacy.
The therapeutic alliance has an opportunity to flourish in the presence of true empathy. Faked or pretended empathy, known at times as role-playing, is not an adequate substitute for the real thing. To experience empathy the therapist must undergo a transient identification with some of the patient's affect. There are probably several reasons why empathy is necessary for a good alliance. The closeness it promotes in the relationship may well be another precursor of the development of a secure holding environment in which the patient can experience caring and nurturing.
Empathy also communicates to the patient, on an emotional level, that he is understood and accepted. When this does not occur, therapy can become an occasion for the intensi- fication of patients' sufferings instead of a source of their relief. It is not unusual for patients to leave therapy prematurely because of failures in this arena Geller, A great deal of what is dealt with in clinical self-psychology is the healing management of empathic failures that occur during the course of therapy Geller, The vital roles played by empathy in psychotherapy cannot be overlooked.
In addition to its necessity in the formation of therapeutic alliances, it is also an essential and irreplaceable element of the therapist's ability to make the "transmutative" Strachey, interpretations that are so crucial in the healing process Geller, It is within the empathic framework that the patient is able to experience interpretations with the emotional immediacy that is essential for their effectiveness.
Geller has viewed therapeutic competence from the perspective and with the terminology of Piaget She believes that empathy enables therapeutic competence because through the use of empathy the competent therapist assimilates patients into his own current concepts of ".
It also allows him to simultaneously accommodate the structure of the work of therapy "to effect a better fit with the unique needs and circumstances of each patient" p. Geller perceives empathy as that which, when conveyed through understandings, is able to move patients though a succession of "more meaningful, coherent connections between disparate, and perhaps disavowed, aspects of experience.
Empathic interventions so conceived serve to combine, unite, and synthesize that which has been kept apart" p. I made no attempt to conceal from him that I was experiencing some part of his pain as he told me about his life and his current fears.
I didn't weep although I felt close to it at times. However, I did let Jake know, in a verbally expressive way, that I was in touch with what he was telling me. It has been called resonance J. Watkins, How much empathy does an effective therapist have to have for his patients?
How does he balance it with the kind of objectivity that is also necessary for him to function properly? Rogers once described the empathic immersion of the therapist in the patient's material as a cognitive endeavor that led him to "understand," but not actually experience affectively, what was going on with the patient. However, Rogers subsequently modified and elaborated his concept of empathy as a process of entering the private perceptual world of the other and becoming thoroughly at home in it.
To be with another in this way means that for the time being you lay aside the views and values you hold for yourself in order to enter another's world without prejudice.
Watkins became interested in Federn's concepts of ego cathexis and object cathexis; eventually, he created his own theory of resonance in psychotherapy. Resonance is that inner experience within a therapist during which he co-feels co-enjoys, co-suffers and co-understands with his patient, though in a mini-form.
When resonating, the therapist replicates with his own ego as close as he can a facsimile of the other's experiential world. Resonance, therefore is a temporary identification established for purposes of better understanding the internal motivations, feelings and attitudes of a patient.
Watkins, , pp. Resonance is effective when the therapist is able to move in and out of it, resonate with the patient, and then step back into objectivity.
Each time the therapist moves back into resonance and then leaves this position for objectivity, he gains a greater understanding of the patient. He may well understand the patient's psychodynamics on an objective, cognitive level, but it is his resonating with the patient that lets him know if it is the right time to give the patient an interpretation about this material.
Watkins thinks that the therapist makes an "ego-loan" to the patient and gets repaid by co-enjoying the therapeutic gains the patient makes.
In this economy, the experiences with the patient contribute to the therapist's own growth, "in strength and maturity as a therapist and a person" J. Watkins, , p. The therapist who is willing and able to make a commitment to such a deep professional 17 involvement with the patient is what Watkins , calls a therapeutic self.
The resonance that is produced and worked with cognitively as well when this therapist and his patient work together brings about a better working alliance and therapeutic outcome.
There are several necessary precautions for the therapist who approaches the development of the intense empathic relationship resonance with his patients. The therapist could fail to oscillate from resonance to objectivity and become lost in the patient's pathology.
Lindner's depiction of the therapist who joined his patients delusional system to effect a cure is much to the point. In his story, "The Jet Propelled Couch" Lindner, , the therapist remained involved with great interest and energy in the delusional system long after the patient had given it up. The therapist could take on too many difficult, suffering patients, forfeit balance in his life, and literally lose himself.
His temporary identification with the pathology of his patients would lead him away from his own states of health. Finally, the therapist could retreat into sheer objectivity as a defense against the painfulness of the temporary identification with the patient that resonance requires.
Zion Psychotherapy Research Group, , which emphasizes unconscious dimensions of the patient-therapist relationship and focuses more on the patient's unconscious contributions. This theory holds that the patient has an unconscious plan for what is needed in the treatment for his own recovery.
Although the patient has the plan, he has been unable to implement it. The therapist's job is to discover what the plan is and help the patient accomplish it. Fusional Alliances Watkins' , description of what happens when the resonating therapist interacts with the patient reflects a viewpoint held by many concerning what actually happens in therapy to strengthen and change the ego.
Certain patients bring extremely primitive transferences to therapy. These may reflect the earliest stages of human development beginning with the symbiotic stage. Symbiosis in Psychotherapy These elements play themselves out in transference-countertransference communications at the deepest levels. Searles called this deep and essential process "the symbiotic core of therapeutic interaction" p.
He called himself the wild analyst Grotjahn, and, in his flamboyant intuitive style, generated many of the ideas and themes that have proved to be relevant in psychoanalysis. Searles reminds us of Groddek's description of the fundamental symbiotic relationship between the therapist and the patient as being one in which the patient unconsciously directed the therapist to do what was needed.
Whittaker and Malone thought that all therapy eventually entered a Core Stage in which the patient saw himself as a "Child-Self," and the therapist's self-perception was as a "Parent. In this the greatest therapeutic depth accrues. Only at this level do the bilateral symbolic relationships converge fully. It is the essential therapeutic relationship in and of itself. It is the relationship which. At times therapists may discover that the therapeutic relationship seems to produce or create fusional alliances between the therapist and patients with primitive and inadequate internal structures.
This replay of the early mother-child relationship or symbiosis can be particularly noticeable in the hypnotherapeutic interaction Diamond, , when therapist and patient cue in to these patient needs in the trance situation.
This important topic is addressed in chapter 7. The reason for its inappropriateness is that it is an experience of "feelings, drives, wishes, fears, fantasies, attitudes, and ideas or defenses against them" that are derived from events with significant figure in the past. They are now directed toward someone else in the present. As noted earlier, however, he distinguished from all of these a positive, nonsexual, transference reaction he called rapport or the effective alliance.
Freud considered all transferences to be inherently ambivalent and believed that rapport was a reflection of the patient's identifying the analyst with positive figures in his past. Because Freud and his followers thought that transference was necessary for the psychoanalytic process, the psychoanalytic situation is designed to bring out transference reactions in patients.
It is only through transference that the analyst is able to discover certain "pathogenic material that is otherwise inaccessible" Greenson, , p. It is doubtful that patients without transference connections to the therapist be they positive or negative could really participate in therapy. The sociopath, cut off from his affective life, does not seem to develop transferences.
However, a primitive transference does exist so that he sees all people, including the therapist, as objects.
Lengthy and careful work must precede the development of obvious transferences in withdrawn schizophrenic patients. The "absence of transference" has been reported in borderline patients as well. Giovacchini noted that the missing transference can be a transference in and of itself for those patients who are deeply alienated from their unconscious processes and who reject the concept of psychic determinism.Nevertheless, emphasis on the value of the patient's most mature efforts in the therapeutic process was not a focus of a great deal of attention.
It is doubtful that patients without transference connections to the therapist be they positive or negative could really participate in therapy. He was over 6- feet tall and only weighed pounds. Another false belief about hypnosis is that it should not be used with dissociative patients because it will cause them to dissociate further. At the same time, he deeply resented the feeling of obligations to others and had no sense of limit setting or appropriate boundaries.