A Mentalizing Approach for Narcissistic Personality Disorder: Moving From "Me-Mode" to "We-Mode".

Narcissistic personality disorder (NPD) is a prevalent condition that frequently co-occurs with other diagnoses that bring patients into treatment. Narcissistic disturbances are not often the chief complaint, but they complicate the development of an adequate therapeutic alliance. Typical countertransference challenges, combined with stigma related to NPD, result in difficulty for the therapist to relate to these patients empathically. Mentalization-based treatment provides a means for therapists to reach these patients by taking a "not-knowing" stance with interest and curiosity in clarifying and expanding a shared awareness of the patient's emotional experiences. By understanding the attachment functions, mentalizing imbalances, and problems of epistemic disregard among patients with NPD, therapists can break through the self-centered "me-mode" of the therapeutic dyad, where the typical lack of engagement or power struggles prevail, to a "we-mode," where the patient and therapist are joined in attention to what happens in the patient's mind and in interactions with others.

A Dialectical Behavior Therapy Skills Group in a Psychoanalytic Community Service: A Pilot Study.

This exploratory study reports on the implementation and effectiveness of a 20-week Dialectical Behavior Therapy (DBT) skills group provided to 8 outpatients (7 women, average age 33 years old) within a psychoanalytic community clinic. We report on the practical implementation of this DBT skills group, and describe how the theoretical/technical differences between DBT and psychoanalysis were negotiated by the two co-therapists. The effectiveness of the skills group was evaluated on standardized measures of borderline personality symptoms, depression, anxiety, interpersonal problems, quality of life, and mindfulness skills that patients completed before and after treatment. At post-treatment, patients evaluated the DBT skills group on a satisfaction questionnaire and therapists completed a countertransference measure. Pre-post outcome data indicated reduced symptom levels of anxiety, depression, and improved quality of life. Both therapists reported moderate therapist responses typically associated with borderline personality disorder psychopathology. Their therapist responses were not associated with symptom levels or change but were related to patient satisfaction. Accumulative pilot studies like these add to the practice-based evidence of DBT components offered within psychoanalytically-oriented community clinics. However, given the exploratory nature of this study, strong conclusions are precluded until further effectiveness research is conducted.

Longing and Fear: The Ambivalence About Having a Relationship in Psychotherapy.

It is unquestioned that reaching the hypnotic state is helped along by relational factors and that, conversely, relational experiences can be deepened through hypnosis. It is also true that deepening the experience of being in a relationship with another person is neither comfortable nor indicated for every patient or therapist. Most humans feel ambivalent about closeness. People vary in their desire for and their skill in sustaining mature intimacy. When we move along the continuum from rudimentary notions about relational factors in psychotherapy, such as rapport, to complex concepts, such as enactments, we move along a corresponding continuum of increasing need for specialized training, supervised experience, and personal therapy. The field of psychotherapy has been plagued from its inception by not knowing what to do with the tensions that emerge when two people listen to and look at each other. Avoiding relational factors may be a very human response to a very daunting matter.

Relationship Factors in the Theater of the Imagination: Hypnosis With Children and Adolescents.

This article examines the spatial and social nature of human relationships with children and adolescents in clinical hypnosis. Beginning with the unique way in which the phenomenon of rapport is intrinsic to the therapeutic uses of hypnosis and is distinct among other therapies, the stage is set for the importance of relational hypnosis. Through the use of case vignettes that illustrate developmental imperatives, relationship factors influencing the clinical interaction are demonstrated in practice. These include transference and countertransference, safety, embodiment, novelty, creativity, respect, trust, equality, being with, loving responses, synchronicity, and empathy. Hypnotic relating exists in a framework through which absorption in play and imagination evokes the child's resources and suggestions are made. In this receptive stance the personalized suggestions lead to an environment for positive change.

['Child witches', analysis of a cultural countertransference]. / Les enfants dits "sorciers", analyse d'un contre-transfert culturel.

The question of "child witches" is a tropism of the transcultural clinic. Caring for these children is a real clinical challenge. It goes beyond the subjectivity of the teenager to include the adults around him or her and the cultural representations which inhabit them. It also addresses the effects of migration, the psychological frailties of the adults and their traditional theories. This reflection shows the decentering work which clinicians need to do.

Play in the analytic setting: The development and communication of meaning in child analysis.

Child analysts increasingly appreciate that play can stand on its own as a mutative process. When the analyst shares a child's "play state," her participation creates a transitional space in which a therapeutic process is enhanced. During play, children experiment with new, improvisational ways of sharing and negotiating meaning between themselves and another. The child and analyst co-create a new lived-experience that can be organized and integrated into a different narrative about the child and his world. This paper demonstrates, through a clinical illustration, how the analyst's participation in play works therapeutically.

Harm in Hypnosis: Three Understandings From Psychoanalysis That Can Help.

Over 50 years of empirical data demonstrate unequivocally that psychotherapy can cause harm as well as good. Two therapist factors increasing harm risk are inadequate assessment of patients' vulnerabilities and certain attitudes/affects. Adding hypnosis as a technique within psychotherapy heightens risk for harm because: (a) trance can unexpectedly expose patient vulnerabilities (through loosening reality orientation, lessening structure, generating unfamiliar sensations and perceptions, and intensifying access to interior information such as emotions and imagery); and (b) trance can unexpectedly increase porousness to therapist's attitudes/affects (through heightening mental receptivity to the internal states of others). A century of clinical data from psychoanalysis offers guidance for protecting against such risks. Concepts of structure, interiority, and countertransference are explicated and translated into practical clinical suggestions for harm prevention.

Psychoanalytic psychodrama in France and group elaboration of counter-transference: Therapeutic operators in play therapy.

In France, psychoanalytic psychodrama is mainly envisioned in its individual form - that is, a single patient working with a group of therapists. Its originality consists in bringing together several clinicians within a clinical experience that is shared as a group. This experience is fundamentally different from traditional individual therapies, psychotherapies or group co-led therapies. Its configuration may be confusing or overwhelming due to the large number of co-therapists involved in the setting. However, thanks to group elaboration based on the transferential-countertransferential dynamics induced by the treated patient, this potential 'cacophony' can lead to fruitful psychic development embedded in play. This is tied to the co-therapists' positioning in the transitional space shared with the patient as well as to the patient's subjective appropriation of their initiatives. By reflecting on clinical material taken from actual sessions as well as from the exchanges and elaborations occurring at their margins, this article shows how psychodrama and group come to metabolize the transferential elements, shaping the engagement of participants in the context of improvised play.

Spirituality and countertransference: Individual and systemic considerations.

Spirituality is now routinely included in the arc of palliative or holistic care. In spite of this recognition, its importance can be compromised unless countertransference in its many forms gains more attention. In this article, individual and systemic considerations related to the intersection of spiritualty and countertransference in hospice and palliative care will be addressed, with particular emphasis on practitioner implications. A framework, developed by Kenneth Pargament will be extended to highlight perceptions that can exacerbate countertransference and spirituality. Practitioner questions useful in eliciting spiritual matters are included.

The Interactive Play and a Persuasive God: A Psychoanalytic Approach to Re-envisioning Pastoral Care and Counseling.

The purpose of this article is to present a sketch of a new image of pastoral care and counseling, which reflects the psychoanalytic understanding of the interacting transference and countertransference matrix, along with a process view of God in a mutually influencing relationship with creatures. A more effective approach in pastoral care and counseling can be conceptualized as the interactive play in which pastoral caregivers and receivers co-create a therapeutic relationship with their own past experiences and their creative capabilities. The interactive play is a concept of describing the mutually influencing relationship in the transference and countertransference interchange. The article introduces the concept of a persuasive God as a new image of pastoral care and counseling which includes aspects of the mutually interacting process in play.

Sandplay therapy with couples within the framework of analytical psychology.

Sandplay therapy with couples is discussed within an analytical framework. Guidelines are proposed as a means of developing this relatively new area within sandplay therapy, and as a platform to open a wider discussion to bring together sandplay therapy and couple therapy. Examples of sand trays created during couple therapy are also presented to illustrate the transformations during the therapeutic process.

An integrative psychotherapist's account of his focus when treating self-critical patients.

This article presents the factors on which I focus as an integrative psychotherapist when treating self-critical patients. I first describe my personal version of psychotherapy integration. Drawing principally from Wachtel's cyclical psychodynamic model, I also incorporate existential and neurocognitive elements highlighting patients' future-oriented thinking and goal-directed action. I then relate this integrative model to the vexing clinical problem of self-criticism. Finally, I outline three types of interventions I attempt to implement in each session: (1) Multiple-Selves Analysis (MSA); (2) Behavioral Activation (BA), conceptualized integratively; and (3) use of therapist's presence.

Clinical process in an integrative psychotherapy for self-wounds.

In this article, I will briefly describe the clinical process of an integrative psychotherapy for the healing of self-wounds, including its intended interventions and the variability of their application and outcome. Four specific strategies will be considered, including (a) the role of empathy throughout the course of therapy; (b) exposure therapy as a paradigmatic treatment for the treatment of feared thoughts, behavior, and emotions; (c) focusing and other experiential interventions for eliciting self-wounds; and (d) modification and healing of self-wounds with an individualized array of psychodynamic, experiential, and cognitive-behavioral strategies. In addition, we will briefly consider the impact of transference and countertransference on the trajectory of therapy.

Integrative approach for the treatment of posttraumatic stress disorder in 9/11 first responders: three core techniques.

We describe an integrative psychotherapy for first responders to the September 11, 2001 terrorist attack, including those who continue to be psychologically impacted by these events, most of whom meet criteria for a diagnosis of posttraumatic stress disorder. Three core techniques used in this treatment are described: (a) an emphasis on meaning making, particularly regarding the traumatic event; (b) focus on the most affect-laden components of the traumatic exposure; and (c) identifying and challenging the implicit strategies used by individuals to avoid discussion of components of their traumatic memories and the attendant negative affect. For each intervention, a theoretical rationale and the presumed mechanism of operation are presented. We discuss the clinical and research implications of this intervention.

What facilitates countertransference management? The roles of therapist meditation, mindfulness, and self-differentiation.

Abstract Countertransference (CT) reactions can negatively affect psychotherapy, and research has found that effectively managing these reactions is positively associated with psychotherapy outcome (Hayes, Gelso, & Hummel, 2011). Therefore, it is important to understand factors that might facilitate CT management. In this study, 78 therapist trainees completed measures of meditation experience, mindfulness, and self-differentiation, and their supervisors rated trainees' CT management qualities. Results indicated that trainees' meditation experience predicted CT management qualities but self-differentiation did not; one aspect of mindfulness, non-reactivity, was related to CT management qualities. Implications for theory, practice, research, and supervision are discussed.

Exploring the therapist's use of self: enactments, improvisation and affect in psychodynamic psychotherapy.

Psychoanalytic psychotherapists, drawing upon intersubjective and attachment theories, recognize that mutual influence impacts the treatment process. Mutual influence generates enactments--emotionally intense joint creations stemming from the unconscious of both therapist and patient--which often leave both patient and therapist feeling confused and stuck. The author presents a case in which the therapist's use of improvisational role play was a critical therapeutic response to an enactment. The therapist's self-expression through the displacement of the role play 1) modeled a safe, affectively genuine engagement in relationship, 2) provided the patient with an unexpected and powerful window into the therapist's emotional world, 3) shifted the patient's fundamental belief that fathers and men are cold and unfeeling, and 4) led the patient to uncover "new" early memories and to become aware of his role as an agent of vitality and intimacy. The author concludes that using improvisation as a flexible response to rigid patterns of enactment may provide a catalyst for therapeutic change.

Clinical implications of The Red Book: Liber Novus.

In this presentation I consider whether the importance of Spirit in Liber Novus may render the task of its clinical application peculiarly problematic. Freud's experimentation on himself is briefly compared with Jung's self-experimentation of which Liber Novus is the record. Taking up the theme of the vas from Gaillard's paper, I refer to Jung's two major contributions to the elaboration of the Freudian frame: the necessity for the analyst to have been analysed, and the positive value of countertransference. In an epilogue, I briefly discuss a dream related to the preparation of this report for publication, emphasizing the theme of the disturbing effects of Spirit as a key theme both in Liber Novus itself and in any attempt to assimilate it on the part of the contemporary analyst.

Relational hypnosis.

This article provides a meta-theoretical framework, which can be applied to hypnosis, based on relational (intersubjective) psychoanalysis. The relationship between hypnosis and psychoanalysis is reviewed by describing three splits: (a) psychoanalysis split off from brain science; (b) psychoanalysis split off from hypnosis; and (c) splits within psychoanalysis itself. Reintegrations of these three splits are discussed from a meta-theoretical point of view--through neuropsychoanalysis and hypnodynamic hypnotherapy (or hypnoanalysis), which combines interpersonal and intrapersonal psychology. Evidence of the mutual adjustments of the hypnotist's style to the needs of the hypnotized is presented, including the unconscious interactional mechanisms that enable these adjustments in the context of relational hypnosis.

ATTEND: toward a mindfulness-based bereavement care model.

Few, if any, mindfulness-based bereavement care models exist. The ATTEND (attunement, trust, touch, egalitarianism, nuance, and death education) model is an interdisciplinary paradigm for providers, including physicians, social workers, therapists, nursing staff and others. Using a case example to enhance the breadth and depth of understanding, this article focuses on attunement as a means to moderate the negative effects of traumatic bereavement, support the framework for posttraumatic growth in the bereaved, improve psychological outcomes for providers, and set the stage for the other aspects of the ATTEND model.

The voices of fellow travellers: experienced therapists' strategies when facing difficult therapeutic impasses.

OBJECTIVE. We wanted to explore how psychotherapists from various theoretical affiliations handle difficult impasses in therapy, in a way that they experience helps the therapeutic process towards further constructive development. DESIGN. We purposefully sampled 12 highly skilled and experienced therapists from the leading theoretical affiliations in the field. We conducted semi-structured in-depth interviews to explore their recall of impasse experiences. Participants were interviewed individually about a specific impasse from their experience that later resolved successfully. METHODS. The transcribed interviews were analysed using a hermeneutically modified method of systematic text condensation. The results that come out of such analyses are 'meaning patterns' or 'themes'. Analyses were technically carried out with the assistance of Nvivo 8 software. RESULTS. Analysing the needs of the therapists when working through the impasses, we found two general themes across the sample: (1) the need for a move--from confusion and bodily tension to shared systems of meaning, and (2) the need for a witness--to find a home for the stalemate scenario in another relationship. We present how having these needs met evokes the experience of (3) the vital clearing--an experiential space between self and impasse. CONCLUSION. We discuss how our findings relate to contemporary psychotherapy theory concepts such as mentalization, mindfulness, and experiential capacity. We discuss our process of reflexivity in carrying out the study and suggest implications of our findings for further research.