Therapeutic Impasse Research Articles

Research on Therapeutic Impasses and Ruptures in the Therapeutic Alliance

In this article, we provide an overview of our research program on therapeutic impasses and alliance ruptures. Beginning in the mid-1980s at the University of Toronto, and continuing in New York at Beth Israel Medical Center since the early 1990s, we have focused our efforts on trying to illuminate the processes associated with resolving ruptures in the alliance and working through therapeutic impasses. Influenced both by the relational turn in psychoanalysis and findings emerging from our own research on the process of change, we have developed and evaluated an approach to short-term treatment that appears promising. We are also developing and evaluating the effectiveness of training methods for enhancing therapists’ capacities to work constructively with negative therapeutic process, regardless of the particular “brand” of treatment they are practicing. Finally, we summarize some preliminary findings regarding the impact of therapists’ capacity for mentalization on both treatment process and outcome.

PS-080 Multiple antituberculosis drug-induced adverse reactions occurring in the same patient: How to treat?

BackgroundThe first-line treatment of tuberculosis relies on four essential drugs (isoniazid, rifampicin, pyrazinamide, ethambutol). This association increases the frequency of side effects of each anti-tuberculosis drug.PurposeTo report a clinical case...

Évolution récente du profil épidémiologique des entérobactéries uropathogènes productrices de β-lactamases à spectre élargi à Marrakech, Maroc

Urinary tract infection by extended-spectrum β-lactamase producing enterobacteriaceae (ESBL-E) is a growing infection risk and may even lead in many cases to therapeutic impasses because of their multidrug resistance. Follow, over a 5-year period, the evolution of the epidemiological profile of uropathogenic ESBL-E and describe their current level of antibiotic resistance. A retrospective work was made over a period of 5 years (from 1st January 2008 to 31st December 2012). It focused on all the ESBL-E strains isolated from all the urinary samples at the microbiology laboratory of Avicenne hospital, Marrakech (Morocco). We noticed in 5 years, an important increase in the prevalence of ESBL-E. The higher prevalence of ESBL-E (51%) was recorded in the urology department. The study of the antibiotic resistance of the ESBL-E had shown antibiotic co-resistances to the ciprofloxacin (82%), to sulfamethoxazole-trimethropim (85%), to gentamicin (74%), to amikacine (51%). Our results also showed, for the first time in our region, an emergence in the resistance of enterobacteria producing ESBL to imipenem (10%). The significant increase in the prevalence of ESBL-E has become a concern at the hospitals and in community medicine as well. The study of the resistance of ESBL-E strains antibiotics showed high rates of co-resistance to antibiotics, including the usual urology molecules. 5.

Moving the field forward: commentary for the special series "Narcissistic personality disorder--new perspectives on diagnosis and treatment".

Comments on the articles by A. E. Skodol et al. (see record 2013-24395-001), E. Ronningstam (see record 2014-42878-005), D. Diamond et al. (see record 2014-42878-004), and A. L. Pincus et al. (see record 2014-01439-001). These articles in this special issue, "Narcissistic personality disorder--new perspectives on diagnosis and treatment", provide useful guidance for all clinicians working with patients with narcissistic pathology, particularly those who may not have considered narcissism as an underlying cause of a patient's presenting difficulties or as a contributor to therapeutic impasse. Taken together, they offer a more conceptually sophisticated approach to NPD than the constraining criteria of the DSM, and make a compelling case that it is time for NPD and pathological narcissism to receive greater clinical and research attention.

Infantile Trauma, Therapeutic Impasses and Recovery

Throughout his writings Ferenczi examines the role of the mother-infant relationship in healthy development as well as the difficulties that occur when that relationship is problematic. This paper using Ferenczi and Bion as theoretical background explores the clinical development of impasse in the treatment of hard to reach patients. These patients present special difficulty for analysis because they are not self reflective although they can be addicted to "processing," which is in lieu of emotional connection. Impasse occurs when the analyst does not detect the mimicry involved in processing. The paper offers the idea of recovery, rather than repair, in that such patients have "gone missing" in infancy. Recovery of lost potential can be found in relationship with the analyst and with significant others.

Repairing Alliance Ruptures in Emotionally Focused Couple Therapy: A Preliminary Task Analysis

For mental health professionals, navigating ruptures in the therapeutic alliance can be difficult. In order to aid practitioners through this therapeutic impasse, the development of an alliance rupture repair model in Emotionally Focused Therapy (EFT) was achieved by conducting a preliminary task analysis. A rational model of alliance rupture repair in EFT was formulated from data analysis of a thought experiment with four experienced certified EFT therapists. The rational model was then compared with the empirical analysis of alliance rupture repair sequences during EFT sessions with a certified EFT therapist. The final rational-empirical model and treatment implications are discussed.

Highly multidrug-resistant HIV: clonal analysis and therapeutic strategies

There are today HIV-infected patients in therapeutic impasses because of highly multidrug-resistant (HMDR) viruses. We studied the distribution of resistance mutations at clonal level, and we analysed the therapeutic strategies used in such cases to achieve undetectable viraemia. The HMDR profile was defined as a genotypic sensitivity score (GSS) ≤ 1.5 for etravirine and raltegravir with full resistance to darunavir. About 30 clones per gene and per patient were sequenced. Virtual phenotypes were determined. Efficacy of therapeutic strategies was evaluated by follow-up of viral loads, CD4 cell counts and trough concentrations of drugs. Among 1310 patients on treatment and with genotypic resistance testing, 25 (2%) were resistant to darunavir and 11 (0.8%) had an HMDR profile. Five-hundred clones could be analysed for four of them. HMDR profiles were harboured by the great majority of clones and all resistance mutations were located on the same strains for all genes. Despite this and a regimen with a GSS <2.0 in three patients, they achieved a viraemia <20 copies/mL. These results were obtained using different strategies: high doses of drugs; combination of antiretrovirals with full or intermediate susceptibility, such as tipranavir, etravirine or maraviroc; and use of alternative compounds, such as foscarnet or interferon. Patients with HMDR HIV were uncommon, but, in such cases, all resistance mutations were borne on the same majority strains. In this study, tipranavir was the only protease inhibitor with full or intermediate susceptibility. Despite very limited therapeutic options, an undetectable viraemia can be achieved by combining different strategies.

Tigécycline : CMI 50/90 vis-à-vis de 1766 bacilles à Gram-négatif (entérobactéries résistantes aux céphalosporines de troisième génération), Acinetobacter baumannii et Bacteroides du groupe fragilis, CHU – Montpellier, 2008–2011

Tigecycline is a new glycylcyclin with a wide spectre including multi-resistant bacteria. Our laboratory tests in routine the in vitro activity of the TGC towards clinically significant isolates of 3rd generation cephalosporins resistant enterobacteriaceae (EC3R), Acinetobacter baumannii and Bacteroides fragilis group (BFG). The objective of this study is to describe the in vitro activity of TGC against these strains isolated between 2008 and 2011 in the university hospital of Montpellier. In this study period, 1070 isolates EC3R including 541 extended spectrum β-lactamase-producers (ESBL) strains, 47 isolates of A. baumannii including 40 multi-resistant isolates and 645 isolates of BFG were tested. Minimum inhibitory concentrations (MIC) were determined using the E-test method. TGC was active against 86.2% of EC3R with a MIC 90 less or equal to 1mg/L (Escherichia coli being the most sensitive species). A. baumannii and BFG were also inhibited at low concentrations of TGC with a MIC 90 less or equal to 2mg/L respectively for 47% and 84.2% of the isolates. Our study confirms the activity of TGC against the EC3R including ESBL-producers strains. The relevance of the therapeutic use of TGC on the BFG isolates with a MIC greater than 2mg/L should be better documented. Often prescribed in therapeutic impasse, the proper use of TGC would require: clarifying the threshold of sensitivity for some species (i.e., A. baumannii, Bacteroides fragilis group); a better understanding of correlation between in vitro and in vivo activity.

CPC-152 Use of Omalizumab in Chronic Cold Urticaria: A Case Report

BackgroundOmalizumab is a recombinant humanised monoclonal antibody which prevents the binding of IgE to the high-affinity receptor type I (FcεRI). A complicated series of reactions results in a reduction of...

Factors influencing the implementation of antibiotic de-escalation and impact of this strategy in critically ill patients

IntroductionA rational use of antibiotics is of paramount importance in order to prevent the emergence of multidrug resistant bacteria that can lead to therapeutic impasse, especially in intensive care units (ICUs). A de-escalation strategy is therefore naturally advocated as part of better antibiotics usage. However, the clinical impact of such a strategy has not been widely studied. We aimed to assess the feasibility and the clinical impact of a de-escalation strategy in a medical ICU and to identify factors associated when de-escalation was possible.MethodsWe performed a retrospective study of patients hospitalized in a medical ICU over a period of six months. Independent factors associated with de-escalation and its clinical impact were assessed.ResultsTwo hundred and twenty-nine patients were included in the study. Antibiotics were de-escalated in 117 patients (51%). The appropriateness of initial antibiotic therapy was the only independent factor associated with the performance of de-escalation (OR = 2.9, 95% CI, 1.5-5.7; P = 0.002). By contrast, inadequacy of initial antibiotic therapy (OR = 0.1, 0.0 to 0.1, P <0.001) and the presence of multidrug resistant bacteria (OR = 0.2, 0.1 to 0.7, P = 0.006) prevented from de-escalation. There were no differences in terms of short (ICU) or long-term (at 1 year) mortality rates or any secondary criteria such as ICU length of stay, duration of antibiotic therapy, mechanical ventilation, incidence of ICU-acquired infection, or multi-drug resistant bacteria emergence.ConclusionsDe-escalation appears feasible in most cases without any obvious negative clinical impact in a medical ICU.

The Role of Culture in Eating Disorders

AbstractA comprehensive understanding of eating disorders should include engagement with the role of contemporary cultural trends. Feminists and critical social theorists have made significant contributions in this regard. Using two clinical cases, this paper contemplates the relationship between culture and psyche in eating disorder, proposing a psychoanalytic conceptualization underpinned by John Steiner's (1982, 1987, 1993, 2011) theory of pathological organizations and psychic retreats. Two conceptual terms will be introduced, namely ‘the normalized body order’ and ‘the abject body object’ to develop the argument. One of the clinical cases will be used to explore a particular kind of therapeutic impasse that can occur when therapist and patient are both female. In this particular case, the normalized body order emerged temporarily obstructing therapeutic progress; the impasse was understood to be an example of the so‐called anti‐analytic third (Straker, ).

Attachement insécure/désorganisé et trouble de personnalité limite : peut-on sortir de l’impasse thérapeutique ?

In this article, the authors discuss the obstacles in the therapeutic relationship with patients with borderline personality disorder because of problematic transference. They present the case of a patient and describe a therapeutic impasse triggered by an exacerbated insecure/disorganized attachment. They discuss strategies to resolve the therapeutic deadlock elaborated according to the attachment theory formulation and the understanding of transference issues.

In our culture, in our gender: Implications of the culture/gender interface for South African psychotherapists

Debates about the relationship between culture and gender, and the potential contradictions involved in simultaneously respecting both multicultural and feminist principles and values, have occupied an important place in theoretical discussion in the social sciences and humanities. This paper examines the relationship between gender and culture from the perspective of the psychotherapeutic encounter in a multicultural society, in this case contemporary South Africa. With the help of illustrative case material involving traumatically bereaved women who became subject to cultural ascriptions of maliciousness or murderousness, and where cultural beliefs potentially jeopardized gender rights, mental health and therapeutic recovery, the article argues that the relationship between gender and culture, viewed from a therapeutic perspective, can be seen to present complex conceptual and ethical challenges for the therapist. In addition, the structural, psychological and discursive positioning of the therapist and client in respect of warrants to speak and to accept or contest cultural constructions is recognized as implicated in particular kinds of therapeutic impasses. Both clinical and political concerns are discussed in order to illustrate the intersections between the intrapsychic and the social, as well as between the personal and the political. Two related lines of theory, that of intersectionality (derived primarily from feminist theory) and of psychoanalytic theory, are proposed and juxtaposed as a productive way of thinking about instances in which the interface between gender and culture presents particular kinds of problems in the consulting room for both clients and therapists. The necessity for a particular kind of critical self, group and cultural awareness is proposed.

Personal Wellness Card Sort: A Strategy for Promoting Relational Healing

This column is designed to underscore relationally based creative interventions used by counselors and psychotherapists in their practices. Our intention is to provide examples of novel, innovative ways of working with clients in their efforts to deepen self-awareness and their connections with others. Although the interventions within this column will be presented in a linear “how-to” manner, an essential premise of this column is that interventions submitted for publication have a contextual and relational basis. Basic to this column is the therapeutic focus of working through latent hurts and impediments to our clients' health and happiness. Client goals generally involve creating the requisite emotional space needed for genuine relational choice for connection to manifest. If you have created a useful therapy tool or if you have adapted an existing creative tool that you would like to share with readers, please follow submission guidelines in the author information packet available at http://www.creativecounselor.org/Journal.html The Personal Wellness Card Sort task is presented as a practical tool for mediating a therapeutic impasse when working with clients who have experienced a traumatic event. The authors describe how this activity can assist clients with viewing themselves in a holistic way, regaining disowned aspects of self and initiating movement toward connecting with others. The process is fully explained, and the authors provide a case illustration involving a client who was the victim of domestic violence and sexual assault.

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.

Psychothérapie des troubles de la personnalité : quand l’impasse n’est pas du côté du client

This article explores the contribution of the psychotherapist to therapeutic impasses occurring with clients suffering from borderline personality disorder, centering on Masterson's concepts of dynamic triad and on impasses resulting from a failure of regulation of counter-transference. The therapist's numerous dynamics-often raised himself in a dysfunctional family-are explored in the possible interactions with the client's pathological dynamic. These dynamics can evolve on a theoretical continuum that goes from predominance of character defences to complete resilience. In conclusion, the very high demands of psychotherapy of borderline personality disorders on the level of regulation of counter-transference, a crucial factor in efficiency and therapeutic alliance are underlined. The author shares her clinical experience supported by a literature review on the mental health and personal life of psychotherapists.

Building Emotional Muscle in Children and Parents

The concept of "emotional muscle" arose from clinical work in relation to therapeutic impasse and as a criterion for moving toward a "good goodbye. "It was applied to work at Allen Creek Preschool, a non-profit psychoanalytic school in Ann Arbor, Michigan, dedicated to the emotional and cognitive growth of families and their children from 0-6 years of age. The idea of building emotional muscle makes immediate intuitive sense to parents, children, teachers, therapists, and patients. It is a bridge between the abstract concepts and findings of developmental researchers and the everyday practicalities of family life, school, and the consulting room. The concept of "emotional muscle" promotes multidisciplinary understanding of personality structure and growth and contributes to the use of multi-modal therapeutic techniques.

EPIDÉMIOLOGIE DES ENTÉROBACTÉRIES BLSE ISOLÉES DES URINES ET POUMONS EN RÉANIMATION

Introduction : The nosocomial infections are of a heavy diagnosstic and therapeutic burden in intensive care unit (ICU). The aim of this study is to determine the epidemiology of ESBL-E as an origin infections of urinary and pulmonary infections diagnosed in ICU. Material and methods : This is a retrospective study conducted over a period of one year which runs from 1st March 2010 to end February 2011 analyzing the results of cellular and microbiological exams of urine and lung samples; and their corresponding antibiograms. Results : Over three hundred and sixty two positive tests, 167 strains of Enterobacteriaceae were isolated (46%); fifty six secretory Enterobacteriaceae ESBL producing were isolated with 33.5%. Separately, Enterobacteriaceae accounted for 84% of bacteria isolated from urine samples against 31.3% of the lung. The proportion of ESBL-E is 33.3% in urine and 33.7% in the lungs. The distribution of ESBL-E shows a predominance of Klebsiella producing about 59%, 44% of all klebsiella are producing ESBL. Discussion : multidrug resistance caused by ESBL-E is a universally finding. The results of this study show the gradual increase in their prevalence as important etiological agents of nosocomial infections and therfore their release into the local health environment. Conclusion : It is necessary again to emphasize the importance of hospital hygiene and good rules of antibiotics to limit the spread of MDR bacilli and avoid the therapeutic impasse.

A time to see and a time to think: therapy and observation with mothers and their infants

In mother-infant therapies, sole reference to the psychoanalytic model can lead to a therapeutic impasse or theoretical inconsistencies. Treatment is greatly enhanced by the dialectic created when one applies Esther Bick's method of infant observation as a framework for thinking and practice. Based on a detailed analysis of the same clinical example, the article examines the different types of therapeutic intervention (ranging from those that draw on infant observation to psychoanalytic interpretation) that can be used over the course of the treatment, but also in the moment-to-moment shifts that occur in a session. This dual theoretical and clinical combination provides a specific framework for thinking and intervening that proves to be clinically coherent and theoretically pertinent in these types of treatment.

Commitment under pressure: Experienced therapists' inner work during difficult therapeutic impasses

Interviews were conducted to explore the recall of impasse experiences of 12 highly skilled and experienced therapists. Participants were interviewed in depth individually about a specific impasse from their experience that resolved successfully. The transcribed interviews were analysed using qualitative methodology. The authors found that participants understood their reported impasse experiences as important for their professional development. The category of “helpful subjective presence” describes the mode of being with patients that the participants found therapeutic. The categories of “losing hope” and “difficult feelings in the therapist in the here and now” are processes that threaten the helpful presence. The participants' inner work on the two latter categories is identified as a key to the successful resolution of impasses.