Intervention Methods with the Individual 2 - Dr. Ribner -2007/8

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Intervention Methods with the Individual 2

Dr. David Ribner

topics include:  

Transference

-first spoken about by Freud. He tried to fix his theories with time, so we have to be careful about which specific time context he was writing about. 

-Freud used "Anna O" to write about transference. She was actually Breuer's patient.

à"Studies in hysteria" – 1895 – 13 years after Breuer treated her (they wrote the book together) 

-all Freud's patients were women and they all had 1 diagnosis ="hysteria"

      àshe was 21, religious, artistic, well rounded education, sharp

            àshe was single

àbreuer was 38.  he started dealing with unconscious – through hypnosis 

-what was her symptoms? –paralysis that kept changing, anorexic, MPD. Started when her dad died. Anna had a role of helping her sick (and now deceased dad.) – this included showering him!!! (eeew!) 

-her symptoms got somewhat better when she came to therapy ("ventilation") = "the talking cure" (coined by Anna Freud) 

àBreuer spent a lot of time on Anna's case (vs. other cases of his) – this caused trouble in his home (though no historical evidence of sex in the relationship)

Definition of transference

-the idea is that emotions that are rooted not in the here and now, but from an (yet) unknown source, which tries to repeat a past scheme

      àpeople try to fix their past – "to have a happy ending" 

Problem:

 
 

Definition of conflict

-2 fantasies which don't fit each other

Psychosis: Freud said that this is an escape from the conflict (vs. solution) 

-some of his students disagreed: i.e. david fenechel: can't blame the patient for anger he brings – sometimes the anger of the patient is legit.! So, therapist also has to check himself too! Another example: some thought that transference is only in the therapy session, but not in outside world relationships 

-projection – defense mechanism – just to reduce tension (by definition of defense mechanism) – transference in not a ego function, but a thing to fix the past 

31/10/2007

We spoke about our internship today

6 or 7th class – transference text – American test 

6/11/2007

Transference

-by definition, it is unconscious. Thus, it is hard to deal with. There is a confusion of time and object. He tried to deal w/ a past object here –and with a different object. Thus is is detached from reality 

Transference reaction: a one time transference episode where something provokes a past scheme of emotion/reaction. But it is not the trend

-it shows our relationship w/ our past 

-transference is not the only way to understand the patient – there are many tools, and transference is one of them – unlike the classic psychoanalytic theory 

Criticism of psychoanalysis: there is blatant ignoring of present! And the therapy processes support regression – but before the session is over, you need to return the patient to present/stability 

-some claim there is an inherent relation b/w transference and resistance

àbecause people are resistant to change! No one wants to change. People do want to feel better, but can't do anything about it.

àpeople rather have the system [others] change and not them. They need to come to a realization that change is only within them and not the system 

-do not assume that if someone brings up content from the past, then there is only transference ài.e. a haredi lady won't look directly at a male therapist. This is from her learnt past, but that is not transference!!!! It is from her past but not an attempt to relive something 

Transference symptoms (you need more than just one to assume transference – but a repetition of a cluster of then)

 

Borderline: 2 trajectory theories:

  1. look for love which is independent of anything. Those who have not received that in infancy –will try that later in life àlooking for the "ideal [dependent]" object. If it does not work, then the patient for looks another thing [after a storm of course]
 

new study: compare b/w 3 approaches

  1. biological approach: MRI shows neural changes – linked to emotional abuse in early childhood, which influenced their psychological brain development [infer: therapy won't work well here]
 

don't forget: one of the defining criteria for borderline is a good reality testing 
 

Distinction b/w ego strengths/functions [same thing] and defense mechanisms

ego strengths/functions: - one of the main things of the ego is to negotiate b/w will and reality. ài.e. so he needs the ability to learn. some claim that even walking/eating is part of the ego. Thus, even in psychotics, they have a basic ego [it helps them survive], but it doesn't help them do higher functions  - so we can ask: what help the patient survive thus far – what needs now to be strengthened 

defense mechanisms: by definition: their only function is to reduce tension. They don't help me solve problems. They just reduce the tension to ego will not be paralyzed. i.e. in trauma, the defenses are shattered, and the ego becomes dysfunctional. They are kinda survival geared.

-some defense mechanisms are more primitive and others are more mature defenses.

 

processes: i.e. in hard cases, i.e. family loss: at first, there is denial [primitive] and later, reality sinks in [and more mature defenses kick in]

-best defense mechanism: humor: it decreases the tension but w/o denial of reality 

-when the stressors are perceived as intolerable, then we tend to regress to previous defenses, since there is a tendency to "believe" that they work 
 

14/11/2007

Freud:

2 drives:

àall energy of id is in calming. The id is not related to reality. Ego is supposed to help the id out. So all of ego's energy comes from the id, since it is supposed to be a servant of the id 

Hartmann:

-some of id's energy is in the ego. But ego has other functions too, independent of the id.

      àso ego has its own functions besides the id and drive, and all the rest. 

--

-important element of therapeutic relation: transference

-another one is the therapeutic alliance – contract – çåæä/áøéú èéôåìé

 

the role of the patient in the working alliance

-in order to gain from psychoanalysis, what does patient have to do? Which patients can to begin with get from which kind of therapy?

-question: what does the patient have to bring:

 
 

reminder: we do not have a mandate to force our therapy onto patients. A person has to come and want the therapy. Everyone has a right to destroy his own life. We might come in when helping others dependent on he person [not adults, but kids], but otherwise, it is anyone's right to self-destruct 

-another reminder: people come for help after numerous attempts to fix their problems themselves. 

àthus we also ask of the patient to ùéúåó ôòåìä – agreeability to work together 

Class-21/11/2007

Neurotic transference: neurotic: only a partial solution to a conflict to the point where there are still remnants of the conflict in the guy's life, including in his transference. 

-until now we spoke about 2 components of therapy

  1. transference
  2. therapeutic alliance
 
 

-real relationship: we have 2 people sitting across from each other, and speak about hard content. So we would be surprised if there would be no real relationship. We'd see it strongly in ending the relationship. It is a problem if there are unethical elements here. –i.e. not crossing the therapist-client relationship. 

Real relationship (term)

 

àbut, transference is experientially real! Even though it is not "real"

-working alliance is also somewhat "artificial" – it is also "true" 

By the way, the therapy has:

 

-so any relationship b/w 2 relationship also has elements of fantasies and elements of reality. Fantasies have an important element in our relationships – i.e. romantic relationships are the more apparent. Some of the fantasy in relationship is transference and some of it is real. The difference b/w any relationships and therapeutic relationship is the working alliance (contract). Any other relationship only has transference and real relationships. Adults have the ability to differentiate b/w reality and fantasy 

Another important element of therapeutic relationship: our inappropriate behavior

-sometimes, the client is reacting to a real that we did. So in those cases, we can't say it is transference. The patient's reaction might be over-reacting or reacting in stereotypically transferential way, the core issue might be in something true/real. Thus, if there is a therapeutic mistake, we have to correct it and not just claim "transference". Sometimes, we might even damage, or at least hinder progress by therapist reaction. He should also to be expected to b/h in "real" ways, but of course on condition that this is for the client's best. 

This leads to the following question: "how much do you bring your personal life into the session, as a therapist?"

-we will speak more about this in counter-transference 

-if we use more classical psychoanalysis, then transference is a core tool. But when we don't do this style ad we probably have shorter treatments then we don't necessary induce it, but we can definitely use it as a therapeutic tool when it comes up. Wolberg, in his article speaks about how to reduce transference when we think that it is not conducive to the therapy [i.e. short term therapy] 

Object relationship – each new object adds to the personality –so you can do transference from other objects to the therapist 

-there are several transference in the same relationship: he could use aggression in order to "protect" the therapeutic relationship –i.e. from "unacceptable" sexual fantasies of his – aggression is more acceptable to this patient than sexuality. 

àis more damaged personality, the transference is more clear. But it is also less warranted to use it 
 

If therapist wants to use transference, you need to allow it to develop and thus you need to be able to tolerate it. don't close it too early. Closing the transference early is good for cases that you do not want to use it. 

àwe need to know what transference does to us as therapists – so that we know how to react 

Philosophic problem:

-we assume that self-awareness of the patient allows him to function better – so we give interpretations. This assumption leads to transference analysis – this assumption is strong in classical psychoanalysis. But we have to take it with its limitation. Not always does self-awareness lead to feeling better. Question: who said that self-awareness leads to feeling better. Optimal disillusionment: I want the patient to understand that how he saw his life is causing his problems. So the therapy is trying to make him see his life differently, but seeing his conflicts and solving them better.

àthis is nice. And important. Yada yada. But! It also has a pessimistic and sometimes damaging message: all your life sucks! – so you need to let him know slowly so he can  tolerate it. too much interpretation will over-explode the patient and he will escape somehow. And on this basis, we need to use transference analysis – with great care. Sometimes, we don't need to interpret it but rather just understand him and react accordingly. 
 

5/12/2007

We had a test on transference today 

12/12/07

Counter-transference

-also came from Freudian literature

-he did not explicitly speak about it too much – because he thought that it is just like transference – just the therapist's transference. The only thing is that the therapist's transference is dangerous.

-expect classical Freudians, no one uses counter-transference like Freud did. 

Freud's counter-transference:

-just like he client's transference – just the therapist having ties to the past and past relationships. This is dangerous: since this is unconscious and unsolved issues.  And thus is an uncontrolled situation of usage of using the client for therapist needs. The client doesn't come to solve the therapist's problems. The source of those problems is in the therapist's early-life past. Thus the therapist's transference can only damage the therapy. The way to solve this potential issue is for the therapist to go to therapy too. 

-so counter-transference is just transference, the other way. 

Modern view of counter-transference

-forget the wording of "counter-transference": in addition to the Freudian counter-transference: the total personality of the therapist as it comes forth in therapy. Not only the past events and conflicts. Thus, counter-transference could be a therapeutic tool, since I can see how I am reacting and feeling and assume how others react to him too.

àthis requires self-awareness, even of hard stuff. 

Theory

Borderline Personality structure: - though this definition is not that accepted, 1/4 of the population falls under this category. Therapists dealing with such people themselves undergo many emotional reactions – frustration, anger, lack of borders

àthis is massive countertransference which those particular patients invoke in therapists. Often, those reactions/symptoms appearing in the therapists are reactions to the patient's disavowed content. 

In therapeutic relations developing slower:

-In therapeutic relationships which develop slower, there is an increase in mutuality and empathy from session to session. In those cases, it is harder to feel the countertransference creeping up on you. This is b/c in those cases, the boundary b/w me as a therapist and me as a person is blurred. Sometimes therapists can't even sense them at all. This is the countertransference which the classical Freudian approach spoke of.

In less stormy therapies, you can speak of counter-transference which stems from the therapist's childhood conflicts 
 

Various kinds of counter-transference:

  1. Freud's classical approach: speaks of anger and love counter-transferences and whatever implications that they have. This countertransfrence could lead to inappropriate/unprofessional b/h by the therapist. The therapist would not really understand the patient but would rather play out his own conflicts or fantasies – its like noise, which blocks our real understanding of what the patient is saying. For example – giving he client a few more minutes  = (grab a finger = grab the whole hand)
  2. Feeling that he must give more: when this feeling stems not from what the client is undergoing, but from the therapist's world
  3. Punishing the client - when this feeling stems not from what the client is undergoing, but from the therapist's world
  4. Seduction: not only in the sexual sense, which is utterly bad in therapy, but in the more subtle way – i.e. to get the client to think that this is the best therapist (when it comes from the wrong motives)
    1. i.e. when each plays a role in the other's fantasy
  5. indirect counter-transference: "the 3rd person in the room" – i.e. what will our supervisor think? – in short, whatever personal we bring into the room. Another example is the pregnant therapist. i.e. so the pregnant therapist has special movements. The added implication of a pregnant therapist is an imminent ending of therapeutic relationship (temporary or permanent). The patient feels that time is running out on his processes – the more the stomach grows, the less he has room
 

Insight

-is not the only thing that will help. Some people's insight doesn't help their problems

ài.e. CBT is very successful, yet doesn't use insight 

26/12/2007

Classical 3rd person in room: i.e. Pregnancy – if we have to end therapy b/c therapist is pregnant, you have to bring it up w/ client – since it was a choice he did not have a say in. we also have to say something about the increasingly apparent third "person" in room – (the baby/the partner of the therapist)

Self-disclosure is also a factor in this therapeutic relationship: that unlike client's fantasies, the therapist has her own partner, not being the client. and that she has a sexual life. We have to accept and bring up in therapy what is apparent to the client about the therapist's life changes/ the most important thing to speak about is the possible eventual ending of the therapeutic relation b/c of the pregnancy 

In hospitals/chronic settings

-those settings have clients where every year, the client gets another intern. So the real relationship is not w/ the person but w/ the institution. This means that it causes some "blockage" in the therapists – b/c they know that the patient won't invest in yet another relationship àthis causes an unprofessional way of thought: "no need or ability to change – he is stable/found his home"/no need to change àwill cause rejection 
 

Counter-transference includes: everything we bring

-how we look/sit

-room furnishing

-place of the institution – center or periphery of institution

      àNIMBY = not in my backyard

-ecological countertransference: touching one part of system influences the all. Changes in our life could change the therapeutic dyad – not only something seen as a wedding ring, but rather the "unseen" things, like an argument you had just before w/ your wife/a loss if the family/etc… - you got to look into it to see if and how it influences the therapy – so it won't harm the therapy/

      àthe client sees it all 
 

-in self-disclosure of the therapist, we have to ask how much it is for the benefit of the client. Don't do it if would harm (classical view), yet if it increases client's awareness/etc…, you should do it (more modern view) 

Main question: is our reactions as therapists stemming from the therapy at hand or our personal conflicts – are we helping the client or ourselves? Are we solving his conflicts or our own? The danger is that the therapist's unconscious will reign in the therapist 

Counter-transference indicators

 
 

2/1/2008

Today in class, we spoke about cross-cultural counter-transference by speaking about our personal ethnicities

20.2.2008

Resistance

-some people think that resistance needs to be dealt with  9b/c it's the therapist's problem 

Resistance – a wall around a thing which he client does around something. This is not a pathology thing but perhaps a health thing – to protect oneself. So we should not immediately undo it! 

1) Therapy is meant to deal w/ tough issues which came up in the client's life. There are probably "scars" in his psychic life, and therapy is mean to help it. for example – if defense mechanisms were supposed to make his survive a bad experience, then reducing the defense mechanisms will obviously invoke resistance. Why stay in the pathological state which the defense mechanisms are trying to defend against? Sometimes, it is better for the situation to leave the thing in the unconscious 

2) any change to an unknown state is anxiety-filled – so resistance is there. And we can't guarantee 100% that if he changes, his disposition will be better then what he was used to for the last 30 years! So we have to respect the client's choices and ìååé  

– so resistance is not pathology but rather an attempt to find a balance. At times, there may be more positive than negative in it 

3) when the client decides he wants change in his life, and he decides that he has to undergo psychotherapy, there might be a message of: you are the faulty/I do not agree with your world view. No wonder that such a message of "you're faulty" receives some resistance. 

Stages of resistance analysis:

  1. we have to see what in us, the therapists, caused the resistance – are we too fast? Too detached from the client?
 

how do we deal with the resistance?

      Two approaches

 

Example: someone wants a second opinion

 

-the literature seems to take the acceptance approach 

Third approach:

Check the therapeutic relationship – why is he not trusting me (his therapist?) why is there no sense of openness? Safety?

Another approach: sidetracking

-avoid the topics which brought up the resistance and instead, speak about other [important] issues – and ask at later stages if he is ready to deal with those original issues 

27/2/2008

Examples and analysis of resistance

  1. client asking about your professionalism: if it done in the beginning – then it is legitimate. At later stages, it may be a question of resistance. We have to see:
  2. ùàìåú çåãøðéåú/intimacy questions – he wants a normative relationship –wants to be normal and not needing therapy. Wants a boundless relationship – because a friendship is not supposed to end. He might want a "perfect therapist" – are you the one who have no problems and the client wants it to rub on to you.  Problem: then it takes away from the therapy process
  3. Silences: not those silences where the patient thinks f new material, but silences of the client not bringing forth therapeutic materials – we have to ask the question of its meaning. If it is resistance, then, the silence is trying not to touch on heavy stuff (i.e. aggressions). It is also an attempt to control the therapeutic process. You can also use art –you can't lie in art. It can also be used as a test – to see how empathic the therapist is. Don't try to cock the guy into speaking. A possible technique is to speak about the importance of the verbal language/speak of fears of using language (i.e. boundless exposure?). language which gets the patient closer to the "tough issues". Speak about defense mechanisms. The best is to speak of this in your fears kind of language – what the silence does to you as a therapist? It could invoke anger/fear/helplessness/boredom (Freud: boredom is similar to anger) – what is for sure is that the silence of resistance is invoked by the patient's lack of security.
  4. Those who try to focus more on the concrete/other: everyone else has to change – just not me.-->touch everything except me. You have to relate to the guy's fantasies and latent wishes. One should help the guy differentiate b/w wishes and reality. In those cases, it is not worth fighting it… the client just feels insecure in the relationship. And you can reject a defensive stance in an insecure position. You can also show the client how his fantasies serve or not serve his goals. Empathy as a tool is needed to build security.
  5. The client who accepts everything/compliments yet nothing changes. This technique gives the client control –over process – you may seem like you are good, but you are bullshit. There are specific things he tries to control – i.e. that he won't loose control of basic drives, that the client fears may run amok.  So he controls it through not touching it.
 
 

How do you treat resistance?

-see where the sources of resistance is – i.e. what is the issue which dictates his life? What are his basic values (superego?) which dictates his life and thus enters therapy through the resistance? You can't treat the superego – it will shatter itself (it’s a weak structure) and will pull down the ego with it. thus the best treatment for anti-socials to deal w/ reward-and-punishment. By the way, even anti-socials have basic values – they have some borders.

-changes have to be done in a secure relationship – so you may have to let the resistance happen for now – until the relationship is secure enough 

Examples/signs of resistances:

  1. in every session, the patient prints on a new topic – so he never touches on anything
  2. talks about everything except the main issue
  3. Intellectualization – he knows everything, intellectually - it allows him to deal w/ issue w/o the "loss of control"àdo not undo defense mechanism w/o having a replacement a hand.
  4. Provocative behavior of client during the therapy session: so therapist deals w/ provocation/aggression and not the real issue
  5. Only some info is given – not to deal w/ the real issue- but it could also further the therapy – i.e. give him time to feel secure – so the therapist should give control over the content. Sometimes, all the informal comes out b/c client feels the control (and therefore more security)
  6. Takes the kids to the therapy/friends coming during home visitations
  7. Flight into health: use with care!!!! The message is "leave me alone" – so the client rather give up symptoms rather than deal with it.
 
 

12/3/2008

Personality disorder

q) what is the difference b/w personality and personality disorder

a) personality disorder – does his thing, yet doesn't solve his anxiety, and his functioning is lowered = personality disorder 

2 factors

 

important:

-we won't see a personality problem in 1 area of life, but in most areas of life to make it a personality problem

-begins in early adulthood 
 

formalities:

-DSM - good tool for organizing thoughts, it’s a syndrome (symptome groups) list. 

-psychosis/functioning/claimed problems -1st axis

-personality – 2nd axis 

Borderline

-mostly women -70-80% 

2 therories

 

Kernberg – 25% has borderline personality structure àmain idea – it’s a range

      àhe thinks that borderline is a bigger category than the DSM says

            àand you can treat those in the not extreme part of the borderline 

Borderline's main feature:

 

-borderlines are chronic patients – some are in therapy for 30-40 years

-masterson: borderline moms make borderline kids – they can't bear his independence

-in some, undiagnosed borderlines, they might succeed in making some things but not other things stable 

Idea: -sexuality- in hope of searching for new/eternal object – to fill the emptiness. 

Narcissistic personality disorder

-i.e. a movie star who likes to see his image on screen – he gets satisfaction and it works, (functioning) then it works àthat is not narcissism

Narcissism characters

 
 

àagain – he is unsatisfied with the situation, which makes it a personality disorder = i.e. fear of rejection is not exactly fun 

-"mix personality disorder" – a mix of several 

Schizoid

 

19/3/2008

Empathy as a therapeutic tool

What is the difference b/w empathy and sympathy?

Question: if you are not sure what the patient is saying, then how do you get to understand him? 

Answer: -the key is to focus on the patient's real emotions

-sometimes people say one feeling to mask a deeper feeling – i.e. anger t/w kids masks his self-esteem. We have to be careful not to unmask it before he has better defense mechanisms. If you don't have a better thing to offer him besides the unmasking, then don't bother! 
 

-So the first thing about empathy is to find out what he feels. You use your own feelings to see how the patient feels 

2 tools:

1) how you feel as a therapist

2) the cause and time and  which it takes place 

When expressing your emotion

 

à "you must feel disappointed because who you need are not here" 
 

26/3/2008

Class change: 28 April+ instead of 30 at 2 

-we had a class exercise on empathy today 

2/4/2008

Projective identification

History

-coined by Melanie Klein. Its definition was changed with time – i.e. Ogden and Kishman 

Projection: put X into someone else. something from sender, and the sender behaves accordingly. In Klein's view, the receiver's behavior is irrelevant. The projection destination could be in fantasy.

Projective identification: the receiver must behave accordingly. There is an attempt to change the receiver, and the mechanism's success is seen in the receivers resulting behavior. Usually, a feared thing is projected 

Stages of projective identification:

  1. the determination of the projector to take something out of himself and the fantasy of the ability to put it somewhere else
    1. some claim: there is an element of control àso he has to be in actual contact with the receiving object
    2. others claim: its just a matter of not wanting to deal with something
 
  1. pressure/manipulation – to cause the other to behave accordingly
  2. when the receiver behaves accordingly, he becomes a "different person", at east in the context of the projector.
 

-usually, most targets do not agree ti take on the projection. There are a natural reaction, such as leaving the relationships/etc… 

Ramifications

  1. the projector will look for someone to project
  2. the projector thinks even lower of himself à"see, no one else wants my shit" – and may look even more desperately for another object to project onto
 

Factors nevertheless maintaining the target in the relationship:

  1. responsibility to the projector/client
  2. it also serves the receiver
  3. love
  4. fear of loneliness
  5. punishment/threats
  6. etc…
 

Role theory

We have to behave in some role way

ài.e. a parent visiting his parents: double role (="role set")

      àroles are not projective identification

            àprojective identification is behaving against one's own nature 

-codependency is a nice word for projective identification. At this point, Dr. Ribner went on a rant about how there is no need for euphemisms since projective identification is supposed to be a neutral word 

4 kinds of projective identification

  1. dependency: the projector seems helpless, even though objectively, it seems he is able. His message is: "you always have to help me! If not, I won't survive!!!"

àbut the more help, the more regression. This dynamic could get to the most primitive (mom-infant) caring. àThe more he receives, the more he asks àdependency only increases helplessness 

Benefits:

 
  1. Power and control: the goal of the projector is control by making the other feel weak. The message is: "you, Mr. projection target, suck! You need me!"
 

When target leaves: both collapse àshows that projector is weak and the target is vulnerable 

Sources of control projective identification

 

àin control projective identifications, the target will feel more weak, so he is more likely to reject it 
 


14.5.2008

Projective Identification – continued

Examples:

1) patient invites the therapist into a sexual relationship

àthe thing is a sexual atmosphere – not necessarily those rare cases of actual sex. The goal of the client in getting the therapist into a continuing and not an ending relationship. The sex becomes the main thing in the relationship. When unanswered, the patient will look for someone else as if to say to the therapist "oh, so you are sexually incompetent". Such a patient wants to feel accepted through sex. This patient probably got messages from parents (as kids) that the value of the kid id based on parental (sexual) satisfaction – again, it doesn't have to be actual sex

àso he lives with the message that self-worth=sexàlong term sexual relationship =self-worth 

Helping:

The message such a patient got is: love=ingratiating others, based on family of origin's messages: other's interests are before yours!

àso everyone will be indebted forever. So therapy can't end and therapist won't leave since he is indebted. Such people assume that love is by what you do and not just by "being" 
 

-one patient could use several kinds of Projective identifications, and if one kind did not satisfy his wishes, he might try another kind of projective identification 

-some theorists say that projective Identification is a transference-countertransference this

-others think that transference-countertransference does not include acting out as well 

Treating projective identification

-Projective Identification will only be in stronger relations. The patient has to feel that the relationship can hold the projected content, as well as a relation strong enough to be treated (fix the original problem àthrough its repetitiveness, hoping for a resolution) 

-if the therapist plays into the Projected Identification fantasy, the patient won't move on, and will just have another disappointment (old story repeated)

-if therapist refuses to play in: the client might feel rejection – because therapist is rejecting significant areas of his personality: his relationship style.

àtherefore, you need empathic reactions to show that you're understanding (yet nit accepting) ->and perhaps explain him what is going on. This can show the client that you are not rejecting him as a person as opposed to people in his past rejecting the whole person for something 

Important: the client needs not only explanations but also feel that it is true. So better to explain in his words àit takes a strong and accepting relationship to be able to see how he always tries to get into the same loop in his life   

-the client might try  to seek  another "target" – based on how he perceives the "rejection" – and therefore, must be dealt with i8n the therapy room 

-you need to help the patient analyze what is going on in the present and past relationships and how they are played out now 

-interpretations need to be emotive and not intellectual. If not, the patient will get into a historical digression instead of the here and now. 

-if we're not aware of the Projective interpretations, our reactions will be unconscious (read counter-transference) and then we will lose control over the psychotherapeutic process. Solution: supervision. 

-the therapeutic process needs to change the Projective identification cycle and not get into it and give it legitimization. 

-whenever the therapist feels weird about something in the relationship, he should ask: is it projective identification? Am I being invited to be somehow else?


--

28.4.2008

Ending therapy/departure

-could be the most important part of therapy

-notify 4 meetings in advance

àall sessions after it will be influenced by the notion of the upcoming ending

àsome will deny that you ever spoke of ending (in short term therapy) 

Otto Rank – "Trauma of Birth"

-this work speaks of departings.

-all through  life, people go through departures – it reminds people of existential death as the baby did from his mom, during birth 

-we all had them but they are still painful.

-if it touches the patient, then it touches us as therapists. So we have to analyze our side of departing issues 

Principles of therapeutic ending

* count down how many sessions we have left

* make it real!!! Speak about its significance

* some will react harshly-anger could be expected 

Freud: 3 conditions for when therapy should ideally end:

1) reduction of symptoms

2) if therapy would end, no regression would happen

3) continuation won't advance the patient 

-in our case (student internship), there is a time limitation – we are done after a year. The significance for the patient is that he has no continuality –while we move on in life 

-in endings, patient will try to control the situation – i.e. deny the situation, not show up, etc… ("You think I have 4 sessions? You are wrong! I have 0!"). in cases where he leaves – try to convince him to have one more session/write letter/refer to other therapist 

-some will go through bereavement process – thus need to cut the relationship completely!!! We need to know and convey how to deal with endings!  

Re-evaluating therapy: (at its end)

-talk about: intake, identified problem, considering the future (i.e. referral – and also make sure that the organization knows about this, so patient won't fall between chairs – usually, patient won't initiate himself!)

-last session: real goodbyes – i.e. with lower-functioning patients, plan what he will do during the times where the sessions used to be)

-prepare patient for next therapist and prepare therapist – by writing clear and full reports


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