Two Are Better Than One: Case Studies of Brief Effective Therapy

By Seymour Hoffman

This volume is a wonderfully clear and integrated exposition of the clinical thinking that goes into the strategies employed by a pair of co-therapists working in Dr. Hoffman’s model. The case histories are brought together here in a manner that summarizes the philosophy and theory of his work. A series of various case histories are written up in sufficient detail with accompanying explanations. --

This book is a welcome addition to the field of psychotherapy. The author skillfully demonstrates that therapy need not follow a rigid script to be effective. The benefits of flexible thinking, creative methodology, yet therapeutically sound interventions may surpass the benefits of standard treatment with a challenging case. This is a wonderful resource for all therapists, demonstrating the need to at times think outside the box to meet the needs of the client. --

• Language: English
• Publisher: Mondial
• Release date: Apr 21, 2011
• ISBN: 9781595692078

Seymour Hoffman

Seymour Hoffman, Ph. D. is a senior clinical psychologist who has worked in various psychiatric hospitals, mental health clinics and a university student counselling service in the last 50 years in the United states and Israel. He is presently employed as a supervising clinical psychologist in a mental health clinic in Israel and is in private practice. He has published over 50 papers in professional journals in the U.S., UK, and Israel and co-authored two books and edited one on psychotherapy. He is listed in Marquis Who's Who in Medicine and Healthcare.

Book preview

Two Are Better Than One:

Case Studies of

Brief Effective Therapy

by

Seymour Hoffman, Ph. D.

Published by Mondial at Smashwords.

Copyright

Golden Sky

New York

Golden Sky is an imprint of Mondial.

Seymour Hoffman, Ph. D.:

Two Are Better Than One:

Case Studies of Brief Effective Therapy

© 2011 Seymour Hoffman

This book or parts thereof may not be reproduced in any form, stored in a retrieval system, or transmitted in any form by any means —electronic, mechanical, photocopy, recording, or otherwise— without the prior written permission of the publisher or the author, except as provided by United States of America copyright law.

Cover: © Golden Sky

ISBN (This Electronic Edition): 9781595692078

ISBN (Paperback Edition): 9781595691965

Library of Congress Control Number: 2011926292

www.goldenskybooks.com

Dedication

This book is affectionately dedicated to the blessed memory of Nili Kuperman, z"l, a wonderful human being and a talented and dedicated social worker and psychotherapist, and to the numerous co-authors and cotherapists with whom the author worked productively over the years.

Table of Contents

Preface

Foreword

Part 1

Dialectical Cotherapy Interventions

Chapter One

Vive la Différence– Dialectical Cotherapy

Chapter Two

Dialectical Cotherapy of a Phobic Patient

Chapter Three

Dialectical Cotherapy of a Selective Mutistic Patient

Chapter Four

Dialectical Cotherapy of a Borderline Patient

Chapter Five

Dialectical Cotherapy of an Anorectic Patient

Chapter Six

Use of a Projective Test in Psychotherapy

Chapter Seven

Dealing with Resistance in an Indirect Manner

Part 2

Brief Interventions of a Consultant in Treatment Impasses

Chapter Eight

Interventions of a Phantom Consultant in Challenging Cases

Chapter Nine

Reflections on Working in a Haredi Mental Health Clinic

Chapter Ten

Humorous Experiences of a Clinical Psychologist

References

Acknowledgement

Preface

The nineteen seventies were years of ferment in the field of psychotherapy. New theoretical and technical ideas emerged. Family therapy was an emerging approach. It was a frontier of new possibilities and its novelty attracted creative minds challenged by those possibilities. It was an exciting time in which new ideas were challenging the Freudian psychodynamic orthodoxy that had been ascendant during the years of my own graduate training years.

The primary novelty of the Family Therapy approach was in its assumption that an individual’s symptoms are based in the dysfunctional relationship patterns of the social system (the family and beyond) rather than in their own psyche. To address these dysfunctional systemic patterns – and thereby to relieve the individual’s symptoms – a whole new set of interventions was being explored.

In those years, the second generation of family therapy pioneers were developing and filling in the sparse framework that had already been laid out by the previous generation of pioneers like Ackerman, Bowen, Whitaker, and others. Presenting, publishing, and sharing ideas in common venues led to much cross-fertilization of ideas.

There were two creative and charismatic individuals that were in the thick of these developments: Salvador Minuchin and Jay Haley. From early years of collaboration at the Philadelphia Child Guidance Clinic, each went on to create their own distinctive model of family therapy. Minuchin and his collaborators were developing the Structural Family Therapy approach and Jay Haley and his collaborators were developing the Strategic Family Therapy Approach.

Minuchin’s work was founded on the premise that when there were appropriate generational roles and boundaries they created a functional family structure that effectively allows its members to negotiate through their life span development crises successfully.The techniques that were developed in this model involved interventions that could reshape dysfunctional patterns and recreate and support proper structural patterns in the family system.

The approach developed by Haley was rooted in the work of Milton Erickson, a hypnotherapist, under whom Haley studied and then collaborated with. Jay Haley‘s work was rooted in the application of strategies that create change. He preferred to avoid – what he considered - cumbersome theoretical frameworks. He collected, devised, and disseminated strategies for change in behaviors/symptoms. He was a proponent of a variety of techniques; among them those that took into account the polarities inherent in inner and/or interpersonal conflict and moving the individual/s beyond in a dialectically synthesizing manner. One such strategy he employed was the application of paradoxical prescription of symptoms which resulted from the paradoxes of the client’s polarities in emotions and intentions. These were tailored to behind the one-way mirror supervision techniques. They also found expression in the Greek Chorus technique developed by Peggy Papp.

Dr. Seymour Hoffman and I had been colleagues on the Adult Psychiatric Inpatient Service in Kings County Hospital in the nineteen seventies. By the beginning of the nineteen eighties, I was drawn to the structural approach and went on to receive formal training from Sal Minuchin in Structural Family Therapy while my colleague, who was by the nineteen eighties working in several clinical settings in Israel, was drawn to and focused his interest on employing the dialectics of change a la Haley. He enlisted co-therapists and developed interventions based on the co-therapists paralleling the patient’s own polarities in carefully chosen complementary roles in the therapy.

His work is based on many of the basic assumptions which underlie the current and highly touted Dialectical Behavior Therapy model developed by Marsha Linehan in the late nineteen seventies and on. Her larger strategy aims to help create a dialectic that would help Borderline Personality Disordered individuals synthesize the intense polarities of their emotional mind and logical mind to a point of a synthesis of the two; the emergence of a wise mind. Her techniques are behaviorally based to reduce emotional intensity of the moment and to allow the space for logical analysis to occur. In the end, the patients are able to modulate their emotions and yet include their emotional issues in their logical process so that they can ultimately act in a wise manner.

In the Dialectical Co-therapy Model developed by Dr. Hoffman, the specific polarities that each patient experiences, that are at the root of their symptomatic behavior, are identified and mirrored by the co-therapist’s complementary roles / interventions. As one dialectic is resolved, the method continues to focus on others which may emerge until change, growth and symptomatic relief are achieved.

* * * * *

This volume is a wonderfully clear and integrated exposition of the clinical thinking that goes into the strategies employed by a pair of co-therapists working in Dr. Hoffman’s model. The case histories are brought together here in a manner that summarizes the philosophy and theory of his work with great clarity. Because a series of various case histories is written up in sufficient detail with accompanying succinct explanations, the scope of his work and its application comes through in a highly readable and very edifying manner.

Reading the case material presented in this volume one can see that the methodology has been applied by the author in individual, group, and family sessions; the flexibility and adaptability of this technique is quite impressive.

While the scope of cases presented is limited to the populations served by Dr. Hoffman and his colleagues, it is easy to see how it can be expanded in other cultural settings and with the cotherapists dividing up their complementary roles in many other ways than the way Dr. Hoffman and his collaborators have been doing.

This slim volume is a pleasurable and easy read. Any practicing therapist will find themselves challenged to think of their own cases in new ways as they read the rich case material and the accompanying clinical rationale presented.

Moses Preiser, Ph.D.

Former Director of Psychological Services,

Kings County Hospital Center, Brooklyn, New York

Foreword

In the history of psychotherapy, the solution to a two-party stalemate often came from the addition of a third party, either on the therapeutic stage itself (the cotherapist or a new family member) or behind stage (the supervisor or team behind the one-way mirror). (Omer, 1994)

Haim Omer makes the salient point that therapists can hardly be expected, when confronted with treatment impasse, to diagnose and transform their unsuccessful perspectives all by themselves. We cannot but view the world through our own eyes; for a different view, we need the help of other eyes. Therefore, an external consultation may prove invaluable for impasse resolution. The goal of the consultant is to first map out the impasse by exploring the narratives, strategies and interactions that create it and then to design a corrective critical intervention to restore movement and direction to the therapy. It aims to give therapy a jolt, release it from the impasse-producing factors and enable normal therapy to be resumed on a new basis. (1994) Omer accomplishes this in his supervisory sessions with supervisees.

Keith and Whitaker, among others, on the other hand, accomplish this by briefly intervening in the actual treatment. As they point out, since the consultant functions with a unique capacity and freedom, as his involvement is brief and passing, he can be more objective, insightful, and free to act and say things that the primary therapist would hesitate or fear to do or say. (Keith and Whitaker, 1983)

This slim book presents examples of treatment cases that depict the effective involvement of cotherapists and brief interventions of consultants in challenging treatment cases and the manner in which they facilitate treatment and extricate therapists from treatment impasses. Part one describes the dialectical cotherapy approach in treating individuals, families and groups and part two describes the effective brief interventions of consultants in treatment impasses. Thirteen brief case studies (plus a group therapy) are presented of children and adults with various symptoms, problems and diagnoses, including , amongst others, selective mutism, borderline personality, phobia, OCD, depression, and anorexia nervosa.

Criticism and objections to the dialectical cotherapy approach

The objections to the dialectical cotherapy approach include:

The use of two therapists is not economical, especially in today’s climate of health-care cost consciousness and accountability.

The dialectical cotherapy approach is very manipulatve.

Responses:

Focused and direct cotherapy significantly shortens treatment, and therefore, in the long run, is economical. The average number of sessions is between eight to twelve. An additional benefit is the live supervision the trainee receives in working with an