Articles de revues sur le sujet « Impasse (Psychotherapy) »

Many clients benefit from psychotherapy sessions that extend across months or years. However, there is a risk for therapeutic impasse in long-term psychotherapy in which the work can become repetitive or with limited gains over time. The current paper provides five transtheoretical principles to increase the impetus in long-term therapy. The five principles include: planful spontaneity, habitual creativity, pushing the limits of the therapeutic alliance, guided discovery, and specific broad goals. The therapist is encouraged to share responsibility for creative flexibility with the client in each session, including within the therapeutic alliance and the real relationship. The therapist can use a series of questions to promote a process of guided discovery. A clear focus on principles of psychology and goals that reflect maintenance of gains, development of strengths, and promotion of enrichment can ensure that the therapy continues to produce change over the length of the relationship.

This article seeks to propose a reflection on the immediate future of psychoanalysis. Winnicott's Third Way, in England, and Lebovici, in France, sought to reform psychoanalysis by focusing on empathic observation and enactment, but reconciling it with the mythical paradigm of the Freudian-phantasmatic model, which created an impasse. In order to resume its development, psychoanalysis needs to carry out a scientific revolution proposed by, among others, Stern and the Boston group in the United States with the theory of inter-subjectivity, and by Coimbra de Matos, in Portugal, with the theory of the New Relation. Continuing along this path, we propose that intimate human relations, and their transformation, constitute the new paradigm of current psychoanalysis. To access this new object, psychoanalysis preferably uses the methodology of inter-intentional observation and intervention. Thus from the quality of the "foreintentional" OU "forward-intentional" attunement, from the analytic pair, there are often spontaneous complementary intuitions, empathic enactments and future-oriented actions that result in new forms of intimate relationship in daily life, new social relations in the world and new meanings for life. This is a proposal that integrates the discoveries of neuroscience and psycho-sociology in psychoanalysis, and psychoanalysis in the other sciences.

The paper describes the structural and procedural picture of the unity of the non-equilibrium state of the individual and a borderline situation. The subject of the study was limited to the situation of loss, for which it was necessary to identify possible scenarios and systematize psychological indicators. The study employed an integrative analysis and synthesis of theoretical and applied works in the fields of personality psychology, crisis and clinical psychology, psychotherapy, and psychological counseling. The unity of one’s state and situation appeared to provide the psychological links of the event, one’s personal predispositions, interpretations, experience, and behavior. The situation unfolds in the external and internal (mental state) reality, which do not coincide. An essential role in correlating of information about the state of the internal and the external and the emergence of a particular state belongs to the psychological boundaries of the individual. The situation of loss reflects the disintegration of one’s internal and external realities and the psychological impasse: the time-space "in between" the previous ego, the future ego and the present ego, which is partially destroyed. The uncontrolled value-semantic "hanging" correlates with the critical non-equilibrium state of a person. The content markers of their unity are confusion, ambivalence, "breakdown" of the ego boundaries, temporal effects, semantic disregulation, disintegration, alienation, and a burnout. Intolerance to ambivalence of a situation means getting into a border situation. The possibility of a constructive or destructive way out of this situation is indicated by affective expansion or semantic dysregulation and disintegration of the personality. Leaving a borderline situation behind requires a change of the state, attitudes, values, and meanings by restoring the eroded or destroyed boundaries of the ego. For this purpose, the borders and the situation connected with them must acquire the status of a problem and a "place" of opportunity in one’s mind.

This paper describes the result of a survey on one Canadian Psychiatric Residency Program. Fifty-four percent of the residents responded to the questionnaire enquiring about their experience of termination in long-term psychotherapy. The majority of residents (66%), had ended therapy prior to fifty sessions. In only a small number of terminations the resident felt the patient was ready to terminate (16%) and that therapy had come to a “natural termination”. Therapy often ended prematurely due to the change of setting of the resident, drop-out and other practical circumstances as well as therapeutic impasses. The paper discusses the factors that influence the premature ending of what the residents undertook as long-term psychotherapy and their implications for their training and the patients’ treatment.

This work proposes a reflection on the specific difficulties of clinical training for the existential-phenomenological perspective. We observed that in the training curriculum in clinical psychology in existential-phenomenological perspective, some difficulties arise due to the inadequacy of the theoretical baggage of newly acquired representations in the course and the kind of comprehensive approach that we are asked to exercise. It is as if the natural attitude of everyday objectifies and crystallizes the meaning of existence and experience of suffering, gaining a reinforcement with the theoretical representations, further blurring the phenomenological attitude of suspension. There is the assumption that the place of psychotherapyst can only be legitimized from a positive knowledge about mental life and, consequently, the attainment of effective techniques for intervention. The experience as students and supervisor training in clinical psychology in addressing the existential-phenomenological psychology course of Fluminense Federal University, shows that these moments of impasse, which installs a “crisis” of theoretical paradigms and professional identities are essential for a redefinition of the role of psychological theories and techniques in the practices of clinical care in the light of a proper understanding of the phenomenological existence.

This presentation summarizes an exploratory study of twelve religiously committed, psychoanalytically oriented clinicians (RPC's). The study, grounded in object-relations theory, employs a clinical interviewing methodology to focus on three primary questions: 1) How do RPC's integrate their psychoanalytic and religious perspectives? 2) How did they deal with religious issues in their own treatments? 3) How do they work with religious concerns with their own patients? A major finding was that religious involvement and the nature of God representations are significantly affected by psychotherapy even when these issues are not specifically addressed in treatment. Another prominent finding was that the clinical style of the RPC was primarily determined by his own therapeutic experience in terms of working with religious issues. Prominent impasses in clinical work with religious patients and religious therapists are enumerated. Paralleling the “compartmentalization of codes” that characterizes the integration efforts of many of the subjects, a dual representation model for God is proposed. The model describes how the adoption of a “public,” abstract God is frequently employed to cloak the maintenance of a highly personal relationship with a private, transitional object God. Five directions for further research are suggested and the capacity for ideology to serve object functions is discussed.

Abstract The use of complementary and alternative medicine (CAM) is wide-spread among cancer patients. Few studies have investigated the use of CAM by patients with haematological cancer patients in Europe. OBJECTIVE: To investigate the distribution and patterns of CAM use by patients with myeloma or lymphoma. PATIENTS AND METHODS: 103 patients with lymphoma and 23 with myeloma (72 male and 54 female) they have responded a questionnaire on diverse aspects of the use of CAM. RESULTS: Ninety-six patients (76.1%) recognize to have used or to use some type or product CAM: Matricaria chamomilla L. (75,3%), Tilia vulgaris (57.4%), green tea (19.8%), Valeriana officinalis L (17.4%), Royal Jelly (17.4%), soya (16.6%), Brewer’s Yeast (7.9%), wheat germ (6.3%), ginseng (6.3%) and aloe vera (6.3%); Cat’s Claw, Hypericum Perforatum (St. John’s Wort), echinacea, grape seed, milk thistle (Carduus marianum), graviola and marijuana (less of 5%). Forty-nine patients (38.8%) recognize to have practiced or to practice oration (23.8%), relaxation (11.9%), oils massages (9.5%), meditation (6.3%), imposition of hands (3.9%) and yoga (3.9%); music therapy, homeopathy, Shiatsu, acupuncture, therapies through of the movement and the dance, guided imagination, psychotherapy, chiropractic and consult with healer (less of 3%). Visualization, hypnosis, biofeedback, chromotherapy, reflexology, or therapies through humour have not talked about or through Internet. They recognize to look for a complement for the traditional medicine (29.6%), to fight the indirect effect (17.4%) or to have control on the own disease (16.6%) not being felt impassive (23.8%); to content the family (3.1%) or to think that its treatment will be faster (21.4%) is other reasons. In 3.9% they tried to replace the traditional medicine. Only the 30.1% “complementary and alternative medicines” knew the meaning the terms. The 62.6% did not know the qualification of the personnel who sells products or applies treatments to him MAC and 36.6% not informs its doctor that take CAM. Sixty-one percent consider that the public system would have to finance this type of practices. COMMENTARIES: This study contributes data on the use of therapies MAC by patients with myeloma or lymphoma in Spain. The professionals we must make the effort necessary to improve our knowledge of the MAC and the formation of the patients; the MAC that demonstrate to their effectiveness and security would have to be able to integrate themselves to the care of the patients.

This article historicises a dream analytic intervention launched in the 1930s by Scottish psychiatrist and future professor of psychological medicine at the University of Glasgow (1948–73), Thomas Ferguson Rodger (1907–78). Intimate therapeutic meetings with five male patients are preserved within the so-called ‘dream books’, six manuscript notebooks from Rodger’s earlier career. Investigating one such case history in parallel with lecture material, this article elucidates the origins of Rodger’s adapted, rapport-centred psychotherapy, offered in his post-war National Health Service, Glasgow-based department. Oriented in a reading of the revealing fourth dream book, the article unearths a history of the reception and adaptation of psychoanalysis from within a therapeutic encounter and in a non-elite context. Situating Rodger’s psychiatric development in his Glasgow environment, it then contextualises the psychosocial narrative of the fourth book in relation to contrasting therapeutic commitments: an undiluted Freudianism and a pragmatic ‘commonsense’ psychotherapy, tempered to the clinical psychiatric, and often working-class, interwar Glasgow context. An exploration of pre-recorded dreams, transcribed free associations, and ‘weekly reports’ reveals that in practice, Rodger’s Meyerian attitude worked productively with Freudian techniques to ennoble the patient’s psychosocial testimony and personal wisdom. This psychotherapeutic eclecticism underpinned and made visible the patient’s concurrent faith in and resistance to psychoanalytic interpretation. Chronicling a collaborative route to psychotherapeutic knowledge within a discrete encounter, the article situates post-war treatment values in the interwar impasse of outpatient psychiatry.

Until the mid 1980s, Bordo writes, anorexia was considered only in pathological terms (45-69). Since then, many theorists such as Malson and Orbach have described how the anorexic individual is formed in and out of culture, and how, according to this line of argument, eating disorders exist in a spectrum of “dis-order” that primarily affects women. This theoretical approach, however, has been criticised for leaving open the possibility of a more general pathologising of female media consumers (Bray 421). There has been some argument, too, about how to read the agency of the anorexic individual: about whether she or he is protesting against or operating “as if in collusion with,” as Bordo puts it (177), the system of power relations that orients us, as she writes, to the external gaze (27). Ferreday argues that what results from this “spectacular regime of looking” (148) is that western discourse has abjected not only the condition of anorexia but also the anorectic, which in practical terms means that, among other measures, the websites and blogs of anorectics are constantly being removed from the Internet (Dias 36). How, then, might anorexia operate in relation to itself?In the clinical fields the subjectivity of the anorectic has become an important area of study. Norwegian eating disorder specialist Skårderud has discussed what he calls an anorectic’s “impaired mentalisation,” which describes a difficulty, as a result of transgenerationally transmitted attachment patterns, in regulating the self in terms of “understanding other people’s mind, one’s own mind and also minding one’s own body” (86). He explains: “Not being able to feel themselves from within, the patients are forced to experience the self from without” (86). While a Foucauldian approach to eating disorders like Bordo’s might be considered a useful tool for analysing this externalised aspect of the anorexic predicament, anorectics’ difficulty with feeling “themselves from within” remains unexamined in this model. Ferreday has described the efforts, in more recent discourse, to engage with the subjective experience of “anorexic embodiment” (140). She is conscious, however, that an enduring preoccupation with “the relation between bodies and images” has made the relations between embodied selves “almost entirely under-theorized”, and an understanding of the lived experience of eating disorders too often reduced to the totalising representations of “abject spectacle” or “heroic myth” (153). In this context Ferreday has welcomed the publication of Warin’s ethnographic study Abject Relations: Everyday Worlds of Anorexia for providing a point of access to the subjective experience of anorectics. One important aspect of Warin’s findings, though, remains unremarked upon in Ferreday’s review: this is Warin’s astonishing conclusion from her investigations that anorexic practices successfully “removed the threat of abjection” for her participants (127). It is exactly at this point in the current debate about eating disorders and subjectivity, and the role of abjection in that subjectivity, that I wish to draw upon the Gothic. As Hogle maintains, abjection has a significant role to play in the Gothic. Like Warin, he refers to Kristeva’s notion of the abject when he describes the “throwing off” whereby we might achieve, in Hogle’s paraphrasing of Kristeva, “a oneness with ourselves instead of an otherness from ourselves in ourselves” (“Ghost” 498-499). He describes how the Gothic becomes a “site of ‘abjection’” (“Cristabel” 22), where it “depicts and enacts these very processes of abjection, where fundamental interactions of contrary states and categories are cast off into antiquated and ‘othered’ beings” (“Ghost” 499). This plays out, he writes, in a process of what he calls a “re-faking of fakery” that serves “both to conceal and confront some of the more basic conflicts in Western culture” (“Ghost” 500). Here, Hogle might be describing how the abject anorexic body functions in the “spectacular regime of looking” that comprises western discourse, as Ferreday has portrayed it. Skårderud, however, as noted above, has suggested that the difficulty experienced by those with eating disorders is a difficulty that involves a regulation of the self that is understood to occur prior to the more organised possibility of casting off contrary states onto “othered” beings. In short, the eating disordered individual seems to be already an embodied site of abjection, which suggests, in light of Hogle’s work on abjection in the Gothic, that eating disordered experience might be understood as in some way analogous to an experience of the Gothic. Following Budgeon, who has stressed the importance of engaging with individual “accounts of embodiment” as means of moving beyond the current representation-bound impasses in our thinking about eating disorders (51), in this paper I will be touching briefly on “pro-ana” or pro-anorexic Internet material before proceeding to a more detailed analysis of Marya Hornbacher's Wasted: A Memoir of Anorexia and Bulimia. Punter, drawing on trauma theorists Abraham and Torok through Derrida, writes that “Gothic tests what it might be like to be a shell […] a shell which has been filled to the brim with something that looks like ourselves but is irremediably other, to the point that we are driven out, exiled from our home, removed from the body” (Pathologies16). In response, I will be suggesting that the eating disordered voice enacts the Gothic by dramatising “what it might be like to be a shell” since that embodied voice finds itself to be the site of abjection: the site where behind its distractingly visible “shell”, the ego, using anorexic idealisation, is compelled to use anorexic practices that “throw off” in an effort to achieve an ever-elusive sense of oneness. Due to Punter's long familiarity and shared vocabulary with a wide range of post-Freudian psychoanalytic theory, I will be particularly referring to his evocations of the Gothic, which he has characterised as a “kind of cultural threshold” (Introduction 9), to demonstrate how an examination of eating disordered experience alongside the Gothic might promise a more nuanced access to eating disordered subjectivity than has been available hitherto. Marya Hornbacher maintains in her memoir Wasted that anorectics, far from hating food, are in fact thinking about it constantly (151). If anorectics always think about food, the visual content of their Internet sites might seem to suggest otherwise: that their thoughts are mostly occupied by bodies—particularly thin, emaciated bodies—which form the material that these sites call “thinspiration” for the “pro-ana” writer and reader. Thinspiration, although not yet recognised by the Oxford English Dictionary, is understood to designate inspiring words or images of thinness that, further to Hornbacher's observations, might be understood as helping the food-obsessed anorectic to manage that obsession. Many pro-ana sites have their own thinspiration pages which, aside from the disturbing frame of the pro-ana verbal content that can include specifying dangerous techniques for abstaining, vomiting and purging, might be little more distressing to a viewer than any readily accessible fashion imagery. On the pro-ana site, however, whether mixed among the seemingly ordinary images or in a section all on its own,the spectre of the walking dead will often intrude. A “pro ana thinspiration” Google image search might yield, similarly, a small cadaverous corner to the purportedly inspiring imagery. It might also yield a tweeted response, from a pro-ana tweeter, to what might have been similar images of thinspiration which, far from affording inspiration, seem to have prompted intense anxiety: “I see the pictures I put up, then I see the morning thinspo everyone tweets, and I just feel gross ..[sic]”. This admission of despair sends a fearful, anxious affect loose among the otherwise serene uniformity of the “thinspo” imagery from which it had ricocheted, apparently, in the first place. Thinspiration, it seems, might threaten just as often as it assists the eating disordered subject to achieve self-regulation through their anorexic practices and, as this screen shot suggests, the voice can offer the researcher a small but potent insight into the drama of the eating disordered struggle.Psychologists Goldsmith and Widseth have stated that Hornbacher’s Wasted “gives the reader a feel for what it is like to live in an anorexic client’s head” (32). Although the book was a bestseller, newspaper reviews, on the whole, were ambivalent. There was a sense of danger inherent in the turbulent, “lurid” details (Zitin), and unresolved nature of the narrative (MacDonald). Goldsmith and Widseth even refer to Hornbacher's reported relapse and rehospitalisation that followed a “re-immersing” in “the narrative” of her own book (32). Kilgour has observed that the Gothic is a space where effects come into being without agents and creations prosper without their creators (221). While Radcliffe's novels might tend to contradict this claim, it is important to note that it is at the borders between explication and a seeming impossibility of explication that the Gothic imaginary draws its power. Miles, for example, has argued that Radcliffe is concerned not so much with dispelling the supernatural per se but with “‘equivocal phenomena of the mind’” (99-102). In Wasted, Hornbacher writes of her fear of “unsafe” foods whose uncanny abilities include the way they “will not travel through my body in the usual biological fashion but will magically make me grow” (20). Clearly, Hornbacher is not referring here to reasoned premises. Her sense, however, of the ambiguous nature of foodstuffs bears an important relation to Radcliffe's “equivocal phenomena”, and indeed the border-defying aspects of Kristevan abjection. In Abject Relations, Warin discovered that her anorexic participants shared what seemed to be magical beliefs in the ability of foodstuffs to penetrate the body through skin or through the nose via smells (106-127). The specific irrationality of these beliefs were not at issue except that they prompted the means, such as the washing of hands after touching food or shoving towels under doors to impede the intrusion of smells that, along with the anorexic practices of starving, purging and vomiting, served to protect these participants from abjection. When Hornbacher describes her experience of bulimia, the force, textures and sheer weight of the food that she eats in unimaginable, enormous quantities so that it bursts the sewer and floods the basement as vomit (223) become all the more disconcerting when the disgusting effects, whose course through the sewer system cannot be ignored, are preceded by evocations of occasions when she anxiously searches for, buys, consumes and vomits or purges food: “one day you find yourself walking along, and you impulsively stop in a restaurant, order an enormous dinner, and puke in the woods” (120-1). Hornbacher’s eating disorder in fact is figured as an insidious double: “It and I live in an uncomfortable state of mutual antagonism. That is, to me, a far cry better than once upon a time, when it and I shared a bed, a brain, a body” (4). This sense of the diabolical double is most evident when the narrative is traversed by the desperation of an agitated protagonist who seems to be continually moving between the constricted upper spaces of dormitories, rooms and bathrooms, and gaping, sewerage filled basements, and whose identity as either the original or the double to that original is difficult to determine. For Hornbacher, even at the end of her memoir when she is presented as almost recovered from her eating disorders, the protagonist not only continues to be doubled, but also exists in fragments: she speaks to herself "as if [she] were a horse", speaking "severely to [her] heart" who will pull her down "by the hair" into a nightmarish sleep (288-289). Punter has elaborated on the way dream landscapes in the Gothic open space into paradoxically constricted but labyrinthine infinities that serve to complicate what he has referred to as the two dimensions of our quotidian experience (Pathologies 123). In Wasted, beds give way to icy depths of watery sleeps, and numerous mirrors either fragment the body into parts or alienated other selves, or yield so that the narrator might step, suddenly, into “the neverworld” (10). Out of the two in the doubling, it is not so much the eating disorder—the “It”—but the “I” that becomes most monstrous as occasionally this “I” escapes onto the empty streets where, glimpsed crouching, anxious and confused in a beam of headlights, she reminds us of Frankenstein’s creature on the mountainsides or in the wastes since, as her capacity to articulate is lost in that moment, she becomes an “othered” object in the landscape (173). When, one winter, Hornbacher develops an obsession with running up and down the hall at her school at five am, she sprouts fine fur all over her translucent white skin and begins “to look a bit haunted” (109); later, in a moment of horrifying self-awareness, she realises that she “looked like a monster, most of [her] hair gone, [her] skin the gray color of rotten meat” (266). Punter writes that it is in the “dizzying heights and depths” of the Gothic that such agitation can become frantic: “in vertigo, the sense that there is indeed nowhere to go, not up, not down, and also that staying where you are has its own imponderable but terrible dangers” (Pathologies 10). Hornbacher states that the “worst night of [her] entire life” was spent with “the old familiar adrenaline rush pumping through [her] [….] running through the town, stopping here and there and eating and throwing up in alleyways and eating and blacking out” (273). This ceaseless, anxious, movement, where it is not clear who or what is doing the pursuing, but clear that it is a flight from the condition of abjection, is echoed in the very structure of Hornbacher’s memoir, which moves back and forth in time, seemingly at random, always searching for the decisive event that might, at last, explain or give a definitive beginning point to her disorders. Not only is the “beginning” of the disorders—an ultimate explanation or initiating event—sought but never found, but the narrative also concludes with an Afterword in which the narrator is, demonstrably, yet to recover, and even as she lies in bed next to her husband, is unable to rest (289). As Punter writes: “In Gothic, we do not directly ask, What happened? We ask, Where are we, where have we come from—not in the sense of a birth question, but as a question of how it is that we have ‘come adrift’” (Pathologies 209)—a question which, as Hornbacher finds, she is unable to answer, but nonetheless is obsessed with pursuing—to the point where the entire narrative seems to participate in the very pursuit that comprises the agitated perambulations of her eating disordered body. Although the narrator in Hornbacher’s Wasted, is strikingly alone—even at the end of the memoir, when she is represented as married, her husband is little more than a comforting body—throughout the text she is haunted by the a/effects of others. Hornbacher’s family is shown to be a community where the principle of nurturing is turned on its head. The narrator’s earliest evocation of herself presents a monstrous inversion of the expected maternal relationship: “My mother was unable to breast-feed me because it made her feel as if she were being devoured” (12). The mother’s drive to restrict her own eating is implicated in the narrator’s earliest difficulties with food, and the mother’s denials and evasions make it all the harder for the narrator to make any sense of her own experience (156). A fear of becoming fat haunts all of the family on her mother’s side (137, 240-1); the father, conversely, is figured in terms of excess (22). When the two grandmothers care for the narrator, behind their contradictory attentions towards the young Hornbacher—one to put her on a diet, the other to feed her up (24)—lies a dearth of biographical material. The narrator’s attempts to make sense of her predicament, where her assertion, “there were no events in my life that were overly traumatic” (195), sounds the edges of this void and only serves to signal that this discomforting contested empty space is traversed, as Punter might suggest, by “the hidden narrative of abuse” (Pathologies 15). Certainly the vague awareness of a great-grandmother who, “a hefty person, was mocked” (98) hints at the kind of emotional trauma that might be considered too abject to be remembered. Punter observes that in the Gothic we are in the wake of the effects of events that we cannot know have even happened (Pathologies 208), and the remains of history that assault us “are not to be obviously or readily learned from; for they are the remains of the body, they are the imaginary products of vulnerability and fragility, they are the ‘remains’ of that which still ‘remains to us’; or not” (Pathologies 12). Hornbacher’s sense of disassociation from her self as a body, and the specificity of her own feelings, which she is only ever able to describe as “pissed or fine” (203), evokes an over-smooth shell, like the idealised images of thinspiration that both belie and reveal their anxious nether sides. Even at the conclusion of the memoir, the narrator still does not “yet” know what it might mean for her to be “well” or “normal” (283). Hornbacher writes: “I always had this mental image of me, spilling out of the shell of my skin, flooding the room with tears” (25). In eating disorders, the self, which has never been whole and entire, or self-regulated in Skårderud’s terms, struggles to self-regulate against the ever threatening encroachment of the abject in a way that suggests essentially Gothic scenarios; in eating disordered self-narratives like Hornbacher’s Wasted, this struggle is evident in the very Gothic dynamics of the text. 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