Two-person Model Research Articles

From Imagination to Information: Therapist’s Curiosity and Voyeurism in the Age of Social Media

Today’s easy online access to personal information has redefined the concepts of privacy, disclosure, and boundaries in all forms of relating. The impacts of this on the therapy relationship have also been examined, but almost exclusively in the context of patients pursuing online information about their therapists. In line with the contemporary relational view of therapy as a two-person model, this article aims to address and explore the reverse; in other words, therapists pursuing the readily available online information about their patients. While it is considered clinically inadvisable for the therapist to seek out more information than what the patient chooses to provide, therapists sometimes privately act on their desire to know more about their patients through checking social media accounts or Googling them. Like many other “secret delinquencies” of therapists, it seems that this behavior is kept in the closet; it is not talked about, thus depriving us of the opportunity to examine it and learn from it. This article first explores how and why it clashes with the analytic contract in an effort to bring a more exploratory rather than critical approach to what otherwise might simply be considered wrong. Then, it aims to examine the complex relational dynamics surrounding this behavior and candidly address some of the deeper questions it raises. Case examples as well as a qualitative review of therapists’ personal accounts are used in an effort to situate this particular type of delinquency in a theoretical and clinical context.

I/I-Thou/It: Muriel Dimen as Clinician

ABSTRACTDrawing upon Muriel Dimen’s paper “Reflections on Cure, or ‘I/Thou/It’” (2010) as my primary point of reference and departure, I attempt to characterize her style of clinical thinking and of her clinical questionings of herself, analytic practices, and the consequences of theoretical predilections. Central to Dimen’s considerations in these clinical essays are reflections on termination, self-analysis, the limits of the two-person model, the therapist’s narcissistic vulnerability, sexuality, and the body.

On Targeting Emotion Regulation Deficits in Eating Disorders through Defense Analysis

ABSTRACTPsychodynamic approaches to the treatment of individuals with eating disorders are underrepresented in research and in academia. This will increasingly deprive patients of a viable therapeutic alternate to the dominant behavioral family-based models. As psychodynamic approaches may have unique benefits, there is value in resolving this loss. Recent models of dynamic therapies for eating disorders within modern, empirically derived theory show promise for future psychodynamic viability. An attachment-focused approach targeting disordered attachment patterns that are common in individuals with eating disorders has recently been introduced. To complement this model, this article proposes an approach for individuals with eating disorders that is hypothesized to target emotion regulation deficits that are also commonly found in individuals with eating disorders. Observed parallels between the implicit branch of the emotion regulation system and that of contemporary constructs of defense mechanisms guide this proposal. Developmental considerations reveal important connections between this biologically based model and a two-person model based in attachment theory. In this way, this proposal offers a flexible psychodynamic approach that integrates with the existing literature. Further development of this approach could one day help patients to have a greater range of therapeutic options for recovery from eating disorders.

Two War-Torn Soldiers: Combat-Related Trauma through an Intersubjective Lens

The author, himself an Iraq war veteran, presents a contemporary psychodynamic understanding, known as intersubjective therapy, of combat-related Post-traumatic Stress Disorder (PTSD). At the onset of this case example, the patient was highly suicidal and his PTSD symptoms had not responded to a first-line treatment: manualized cognitive processing therapy. Robert Stolorow's intersubjective, psychodynamic approach to traumatic emotional experiences was then selected for treatment, and illustrates how combat in Afghanistan shattered this soldier's world and self experience. Therapeutic action arises from this intersubjective perspective by providing a relational home so that unendurable emotions can be borne, processed, and integrated to achieve a more constant and individualized sense of self. Being a two-person model of therapy, the author also describes how his work with this traumatized soldier affected him, ultimately contributing to his own sense of authentic existing. The author discusses the need for therapists to recognize and acknowledge to traumatized patients their shared finitude and the ubiquity of trauma. In the Postscript, the patient describes what he felt was therapeutic and contrasts this to his previous experiences with manualized cognitive processing therapy.

The Relationships Between Senior Auditor Budget Participation, Job Structuring, Job Consideration And Staff Auditor Time Budget Pressure

This study employs a two-person model to examine relationships between senior auditor behaviors and staff auditor time budget pressure (TBP). Specifically, the study examined the relationships between staff auditor TBP and (1) senior participation in the audit budgeting process, (2) senior structuring of staff auditor's job tasks, and (3) senior consideration of staff auditors. Senior audi- tor subjects were asked to indicate the extent of their audit budget participation on a specific audit while the staff auditor subjects were asked to respond to questions indicating the extent of senior job structuring and consideration on that same audit. Both senior and staff auditors were asked to indicate their perceptions of the staff auditor TBP on the specified audit. Surprisingly, the results showed no correlation between senior and staff auditors' perceptions of the extent of the TBP faced by the staff auditors on the specified audits. Specifically, greater senior budgetary partici- pation was associated with higher staff auditor TBP perceptions (i.e., positive association) while, on the other hand, senior auditors perceived staff auditors as having less TBP when there was greater senior budgetary participation (i.e., negative association). Finally, less senior job structuring of the staff auditor’s job tasks was found to be associated with greater staff auditor TBP (i.e., negative association) while only mixed evidence of an association between senior auditor consideration and staff auditor TBP was found.

This Better Be Good! Complex Systems and the Dread of Influence

As much as a bidirectional model of influence has enhanced our understanding of the therapeutic process, this article argues that reliance on two-person models has limited our ability to explore the role that influence plays in therapeutic action. From a psychoanalytic complexity perspective, the manner in which the dyad adapts to influence is a dynamic, emergent property of numerous systems in which the dyad itself is embedded. The conditions that support the dyad's capacity to adapt to and use influence in a manner that builds complexity and supports therapeutic change are explored and contrasted with the qualities of systems that “dread influence” and tend to resist change. From a complexity perspective, therapeutic action involves the dyadic capacity to adapt to one another, as well as to these multiple sources of influence, and to self-organize in a manner that produces and sustains therapeutic change.

Partners in treatment: relational psychoanalysis and harm reduction therapy

A relational psychoanalytic harm reduction orientation to the treatment of substance misusers is presented and illustrated with a clinical example. Both harm reduction therapy and relational psychoanalysis rely on a two-person model in which the therapist and client are collaborators in the treatment. In both, substance use is seen in the context of the user's internal psychodynamics and external environment, and there is an emphasis on treating the person as a whole individual whose substance use is one aspect of life, rather than focusing on the substance use itself as was often done in the past. Historically, psychoanalysis and substance abuse treatment were so different from each other that their paths rarely crossed. The introduction of harm reduction therapy to substance abuse and the relational orientation in psychoanalysis have brought the fields closer together such that the valuable contributions that each can make to the other can now be appreciated.

Discussion of Craige's “Terminating Without Fatality”

Craige's concept of termination and the related concept of post-termination contact are based on Freud's early, one-person model of analytic therapy as a medical treatment for the cure of a disease. Post-termination contact was considered appropriate only if the patient needed additional therapy. Subsequent development to a two-person model of treatment, which recognizes the critical importance of the patient–analyst relationship, requires modification both of concepts of termination and of post-termination contact. I propose that whether there should be such contact, and what it's nature should be, should be mutually decided by patient and analyst in the termination phase, based on their risk/benefit evaluation of such meetings. The intimate, loving patient–analyst relationship, which has enhanced the patient's development, should be able to continue in some form after the end of treatment unless substantial, unresolved problems of either patient or analyst proscribe such meetings.

Symposium: On the Interface of Kleinian and Intersubjectivist Approaches to a Clinical Case

This symposium is the first of what we hope will be a series on the interface between Kleinian and intersubjective/relational approaches to psychoanalysis. There are some commonalities between these approaches that may not be entirely obvious. The Kleinian clinical approach organizes the internal world in terms of internal object relationships, and relies on attention to certain aspects of the countertransference as the central data source for analytic work. Both of these qualities provide an immediate link to the two-person model so central to the relational turn. At the same time, the Kleinians' radical insistence on the primacy of the internal world and in particular, the world of the primitive phantasies, runs counter to the relational interest in the equally important role of actual, social reality. This contrast is perhaps most acute in their approaches to the analyst's participation in the analytic dyad, which is meant to be limited to particular analytic functions in the Kleinian approach, but acknowledged and used as a part of an interpersonal relationship in the relational model. As the Kleinian perspectives gain currency in the United States and international interest in the relational approach grows, an exploration of these complex conceptual and clinical differences and similarities seems quite timely.

THE CONCEPT OF OBJECTIVE COUNTERTRANSFERENCE AND ITS ROLE IN A TWO-PERSON PSYCHOLOGY

Objective countertransference comprises those feelings the analyst experiences with the patient that are repetitions of feelings from the patient's life outside the analysis. It is viewed as being induced by the patient and is understood in the context of the patient's life, not the analyst's. The concept is used to understand the relationship of some of the analyst's feelings to recurrent interpersonal patterns in the patient's life. It has often been viewed as being incompatible with a two-person psychology. Here, in contrast, it is argued that objective countertransference is only one current within the analyst's total emotional response to the patient, and that it should be conceptualized as a component of a broader two-person psychology. However, the use of objective countertransference as a conceptual tool highlights aspects of the analytic relationship that differ from those emphasized in current two-person models. A case example is analyzed from both perspectives to illustrate their similarities and differences. Although the concept of objective countertransference can enrich the analyst's understanding of certain dimensions of the analytic relationship, it is not a theory of technique and it is not wedded to any particular style of psychoanalytic intervention.

Drs. Kay and Gabbard Reply

Back to table of contents Previous article Next article Letter to the EditorFull AccessDrs. Kay and Gabbard ReplyJERALD KAY, M.D., , and GLEN O. GABBARD, M.D., JERALD KAYSearch for more papers by this author, M.D., Dayton, Ohio, and GLEN O. GABBARDSearch for more papers by this author, M.D., Houston, Tex.Published Online:1 Jan 2003https://doi.org/10.1176/appi.ajp.160.1.186-aAboutSectionsView EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: We welcome the opportunity to respond to the important points raised by Drs. Waterman and Batra, Lissak, and Grunebaum. First, Drs. Waterman and Batra are concerned that we obfuscated the issue of dualism by suggesting that split treatment (in which a psychiatrist might provide pharmacological treatment and a nonmedical mental health professional might provide psychotherapy) is not representative of a Cartesian-based practice model. They argue that the provision of such services is unrelated to a dualistic approach. Although a two-person model of treatment may certainly be implemented in a way that eschews dualism, it is, in fact, this split treatment model that has led clinicians and the general public to reify an artificial separation of mind and brain. As Drs. Waterman and Batra acknowledge, we are fully aware that psychotherapy should not be artificially relegated to “disorders of the mind” or “psychologically based disorders.” However, we feel that a split treatment approach forces clinicians to adopt a conceptual model that strengthens the mind-brain split rather than dissolving the mind-brain barrier. We wish to note also that there is emerging evidence that psychotherapy and psychopharmacology may be affecting the same or similar neural pathways (1).Dr. Lissak has had difficulty finding mentors and teachers who are proficient in combining psychotherapy and pharmacotherapy. We noted in our article that integrated treatment is neglected in many training programs, and we hope that situation will improve now that it is mandated as one of the core competencies. But we strongly disagree that the two approaches are incompatible. Many of us combine them every day and teach our residents a systematic approach to integrated treatment.Dr. Grunebaum appeals to us as clinician educators not to dismiss the social characteristics of our patients. We believe he is right that educators often give short shrift to the social context of our patients. Both of us have written about the centrality of family interventions in the treatment of schizophrenia, bipolar disorder, and some cases of severe depression. We concur with his citations in the literature to that effect. We believe that attention to family, marital, and ethnocultural considerations are vital to the effective treatment of our patients.Reference1. Thase ME: Neuroimaging profiles and the differential therapies of depression. Arch Gen Psychiatry 2001; 58:651-653Crossref, Medline, Google Scholar FiguresReferencesCited byDetailsCited ByNone Volume 160Issue 1 January 2003Pages 186-a-186 Metrics History Published online 1 January 2003 Published in print 1 January 2003

The fate of integrated treatment: whatever happened to the biopsychosocial psychiatrist?

The authors suggest that pharmacotherapy and psychotherapy, the major treatment modalities in psychiatry, have become fragmented from one another, creating an artificial separation of the psychosocial and biological domains in psychiatry. After a brief discussion of the economic factors influencing this trend, the authors provide a selective overview of recent research. In the absence of systematic empirical data regarding which patients and which conditions might benefit from integrated treatment by one psychiatrist, the authors propose specific clinical situations that call for such integration and also discuss concerns about cost-effectiveness. Recent research suggests that combining psychotherapy and pharmacotherapy may have advantages over either treatment alone in certain clinical situations involving specific disorders. While few of the studies on combined treatment have tested whether a one-person or two-person model of treatment provision is more effective, there are a number of advantages to the one-person treatment model in which a psychiatrist conducts the psychotherapy and prescribes medication for the same patient. The authors suggest that further research is needed to clarify the optimal situations for the one-person model of integrated treatment and also propose systematic teaching of integrated treatment in all residency training programs.

Integrating One-Person and Two-Person Psychologies: Autochthony and Alterity in Counterpoint

The classical psychoanalytic concept of the one-person treatment model and its assumptions concerning psychic reality are compared with the contemporary two-person model, subsumed under the concept of "alterity" (otherness). The classical model of unconscious mental life is explored in terms of the principles of "autochthony" (signifying the fantasy that self and object are created entirely from and by the self) and "cosmogony" (an aspect of primary and secondary processes that accounts for the creation of a personal and an objective world-view). Autochthony and cosmogony are subsumed under the category of "creationism." I discuss why I identify these three phenomena by these relatively unused terms.

Evolution of Beliefs and the Nash Equilibrium of Normal Form Games

The paper formulates a simple two-person model of learning with pattern recognition and discusses its implications. In particular, it focuses on the asymptotic behavior of players' beliefs when the game has a mixed-strategy Nash equilibrium.Journal of Economics LiteratureClassification Numbers: C72, D83.

Interpersonal-relational psychoanalysis: An introduction and overview of contemporary implications and applications

Abstract For half a century Interpersonal psychoanalysis has developed relatively independent of the tradition of Freud and his followers. The Interpersonal movement was founded by Harry Stack Sullivan, Clara Thompson and others who believed that the psyche could not be understood as an entity that evolves without input from the external environment. The Interpersonal view is that interactions between people influence every aspect of the individual's experience, and that no person can be studied without simultaneously noting the ongoing impact between the observer and the observed. This line of thought has led to conclusions concerning personality, psychopathology and clinical technique that depart from traditional psychoanalysis. The paper illustrates a number of these differences, emphasizing that the current emergence of the “two-person model” of the psychoanalytic situation offers a potential rapprochement between the Interpersonal and more classical views.

Welfare Programs and Donor-Recipient Adjustments

Recent discussions of in-kind contributions versus money transfers in welfare programs provide the point of departure for this article. Using a two-person model where utility interdependencies exist, a donor-recipient interaction process is described. The conditions under which donor-desired consumption might be elicited from the recipient are also presented. Through the use of the model, potential donor-recipient adjustments are identified which might frustrate the intent of in-kind welfare programs.

EFFICIENCY IN THE PROVISION OF CONSUMPTION SUBSIDIES

SUMMARY There are numerous devices which are used to affect individuals' consumptions of various goods—direct distributions of goods, vouchers, price-reductions, etc. This paper investigates the efficiency aspects of these devices. In a simple two-person model, it is shown that lumpsum transfers of a good whose consumption yields external benefits will lead to neither optimality nor equilibrium. But a price cut, an alteration of exchange ratios, can produce an optimal equilibrium. In a model in which there is one subsidy recipient and many benefactors, it is shown that in certain cases a transfer of the externality-generating good, of an equal amount of money, or of some other good will all produce the same effect in the individual's consumption of the externality-generating good. A price reduction on an ‘all-or-nothing’ subsidy scheme, in which the individual must pay a given amount for a given quality of the good or receive none at all, will lead to optimality. When there are many givers and many receivers, an efficient subsidy device will in general not be one which faces all individuals with the same conditions. Price reductions, all-or-nothing schemes, and legal standards are shown to be alternate ways of reaching optimality, differing mainly in the way in which they affect the distribution of real income.