Psychotherapy for Cardiac Patients?

This article explores the mutual, interactive influence between cardiovascular disease and mental health. The psychological issues present among patients of cardiac health issues are mainly that of anxiety and mood disorders. Often termed “psychocardiology”, this field integrates both medical aspects of cardiology and psychotherapy.

The interactions between the mind and body are pronounced and evident. When we feel anxious, our heart pumps faster and we feel breathless. The interaction between psycho and soma is also complex and multifaceted.

Cardiological and psychiatric disorders are closely interrelated and have a bi-directional relationship. This is what we understand as a psycho-somatic interaction.

Mind and Body Connection in Cardiology

Cardiovascular disease is among the leading cause of morbidity and mortality in the industrialized world.  While psychiatric disorders have a prevalence rate close to 20% of the population, depressive illness  is one of the leading cause of disability worldwide (Murray & Lopez, 1997). 

Put together,  depression and anxiety related to depressoin is identified as a significant risk factor for mortality in patients with coronary heart disease (Barth et. al. 2004).

cardiovascular disease and depression

The article cites a meta-analysis of research papers and have found that depression and anxiety contributes to the mortality of patients of coronary heart disease. Cardiac patients who suffer depression are 2x more likely to die than cardiac patients who do not suffer depression in the 2 years of initial assessment of the disease.

Halaris (2013) highlights links underlying recognized cardiovascular disease and mood disorders. Genetic and epigenetic factors affect how an individual reacts to mental and biological stress. Psychosocial and environmental stressors together with lifestyle choices also determines susceptibility to level of disease states.

Among patients with Congenital Heart Disease, for example, it is found that illness perception of the patient is a significant predictor of  patients’ quality of life, cardiac anxiety and depression one year after the heart intervention (O’Donovan 2016). It indicates that how the patient see his/her illness and the self in this situation affects his/her health development and quality of life.

Psychological effect of Diagnosis of Heart Defects on Patients

Being diagnosed with heart complications, whether it is congenital heart disorder or coronary heart disease leads to years of continuous physical, psychological and/or social burdens for the patient and family.

Patients with early-recognized congenital heart defect live with the condition throughout life. This is especially so in the case of babies / children diagnosed with congenital heart defect.  The psychological state of these patients is deep rooted becomes embedded in identity.

Encased in the anxiety of other types of patients whose heart disease emerge later in life is the shock/abruptness of the heart failure due to a previously unknown / undetected defect. This further stir associations regarding health in general (loss of former self-identity, increase of insecurities etc.).

Psychotherapy needs of Cardiac Patients in Cardiology

Medical professionals in countries like Austria realize the need for an integrated-method of treatment of cardiac patients. Medical treatment is more focused upon when the symptoms are acute, and with chronic ailments the psychological work take precedence. Many fields of mental sciences work together with the doctors for after-care of the patients.

Psychotherapists, as per the studies cited in this article have un-covered the major psychological issues patients face: Clinical anxiety coupled with depression. These have also been shown to have adverse affect on the health development of the patients.

Anxiety is an increase in the awareness of psychic or physical sensations to a degree that makes it impossible for the real or imagined danger to be avoided; there is a constant danger signal together with the incapacity for active coping (Waelder, 1960). Relaxation in the tensions of anxiety seeks the experience not of satisfaction but of security (Sullivan, 1953). 

Patients come to psychotherapy with existential anxiety because of their life-death situation.  Illness perception is linked to these feelings. Along with it comes the perception of oneself in relation to a defect. Patients talk about the feeling of being vulnerable, ‘damaged’, ‘weak’.  For adult patients (especially those who are independent in life), these experiences are often concealed from relevant others.  

In therapy, these themes are worked through in the confidentiality and security of the session. The psychotherapist for such patients has to possess the resources to contain the very strong emotions of the clients, approaching the sessions with empathy and patience. Patience is normally understated, but important. Many patients take time to trust the therapeutic process, and may discourage the therapists from helping them. Feelings of hopelessness /helplessness do become projective identification.

“.. the therapist should function as a container of the patients’ anxieties. The fundamental therapeutic task at this stage is the analyst’s containment and interpretation of the patient’s anxiety. To the extent that this process is carried out, if the patient deposits—or rather evacuates — his anxiety and the analyst is able to bear it, a type of relationship is established in which the patient feels the analyst is an object who’s function is to contain him … As this process repeats itself, the patient develops a growing confidence in the relationship and gradually introjects ‘it’. It can be said theoretically, that from the moment there has been sufficient introjection, the patient has (achieves) within him an object where he (from now on) can deposit his anxieties … “

(Etchegoyen, 2005, p. 620).

The therapists who is able to see through the difficulties of the therapeutic sessions eventually builds the sound alliance. He/she is then able to support the client through the worst of feelings (especially that of loss), thus alleviating existential loneliness and isolation that is part of the depression.

Psychotherapy for Parents and Siblings of Children with Congenital Heart Defect

Psychotherapy cannot ignore that alongside a patient is his/her social system. Parents and siblings of child patients bear a big burden. Work with the family on a long term basis helps alleviate chronic stress faced by parents and supports the family. We can take heart from the research mentioned by Re (2013).





Barth, J., Schumacher, M., & Herrmann-Lingen, C. (2004). Depression as a risk factor for mortality in patients with coronary heart disease: a meta-analysis. Psychosomatic medicine66(6), 802-813.

Etchegoyen, R. H. (2005). The fundamentals of psychoanalytic technique. Karnac Books.

Halaris, A. (2013). Inflammation, heart disease, and depression. Current psychiatry reports15(10), 400.

Murray, C. J., & Lopez, A. D. (1997). Global mortality, disability, and the contribution of risk factors: Global Burden of Disease Study. The lancet349(9063), 1436-1442.

O’Donovan, C. E., Painter, L., Lowe, B., Robinson, H., & Broadbent, E. (2016). The impact of illness perceptions and disease severity on quality of life in congenital heart disease. Cardiology in the Young26(1), 100-109.

Re, J., Dean, S., & Menahem, S. (2013). Infant cardiac surgery: mothers tell their story: a therapeutic experience. World Journal for Pediatric and Congenital Heart Surgery4(3), 278-285.

Humiliation, Shame and Violence

This is a presentation I gave some years ago on the connection on antisocial violent behavior in some men, and how researchers (in this article I feature the work of J. Gilligan) have learnt how these violent behaviors are linked to culturally-adapted values. Such values function as introjects in individuals. The resultant of which is violent and aggressive emotions as consequence of displaced feelings of humiliation and avoidance of shame.

Mass shooting incidents do happen and the perpetrators leave behind chilling messages that point to a root cause, which Gilligan has pointed out.


Here are the list of extreme cases of violence in young males. The motives for their actions were later revealed to have mysogynic undertones. Many express their hatred for women.

Working with Shame

  • Empathic understanding of the patient’s experience with shame
  • Assist the client to understand fully this experience.
  • Showing warm understanding, acceptance and respect.
  • To heal shame, the therapist must understand shame. Therapist must understand this in context of the patient.
  • Therapist must be committed to dialogue.

(Yontef, 1996)

  • Hold the client in unconditional positive regard.

Working with Humiliation

Why Humiliation?

Shame is related to humiliation, but they are not the same emotions.

The Phenomenological difference between Shame and Humiliation

  • Humiliation relates to distinct “self and other” interactions, and to distinct levels of self-definition.
  • Humiliation is done by one person to another purely for own selfish purpose.
  • Humiliation implies an activity occuring between oneself and another person.
  • “Humiliated” is a feeling of position of oneself in relation to another or others. It is also an interpersonal interaction.
  • Humiliation is the feeling of an act of being put into a powerless, debased position by another who at a point in time posesses greater power than oneself.
  • Humiliation can involve anger over one’s lowered status.  (Gilbert & Andrews, 1998)


Anderson, E. (1994) The Code of the Streets. The Atlantic Monthly 5 81-94

Cohen, Vandello, Rantilla (1998) The sacred and the social . Cultures of honor and violence. In P Gilbert, B Andrews (Eds.) Shame: Interpersonal Behavior, Psychopathology, and Culture pp.261.

Gilbert, P. E., & Andrews, B. E. (1998). Shame: Interpersonal behavior, psychopathology, and culture. Oxford University Press.

Gilligan, J. (2001) Preventing Violence. London: Thames & Hudson.

GILLIGAN, J.. (2003). Shame, Guilt, and Violence. Social Research, 70(4), 1149–1180. Retrieved from

Herbert, B. & Gilligan, J. (2014) Bob Herbert’s Op-Ed. TV: Dr James Gilligan on our Culture of Violence. Youtube Video.

Retzinger, S. M., 1995 Identifying shame and anger in discourse. American Behavioural scientist 38(8) 1104-1113.

Yontef, G. (1996) Shame and guilt in Gestalt Therapy. In R. Lee & G. Wheeler (Eds) The Voice of Shame. San Francisco: 390. pp. 370-371.

The Neuroscience of Language Explains How and Why Psychotherapy Cures

Drawing much inspiration from a lecture given by Sapolsky (2011), an expert in the neuro- and biological field, I would like to discuss the use of language, or — more accurately put– communication, as a cure for psychological pain.

The profession of Psychotherapy, at its formation, was termed the “talking cure” (Freud & Breuer, 1895).  This literally means talk as a means of relieving one of symptoms or psychical and often also somatic nature. What the term “talking” does not describe is the “listening” from the other person. In psychotherapy it is the talking to someone who is actively listening that cures. Read also: The Psychotherapeutic Alliance.

Language is in verbal and non-verbal communication

Talking and listening is communication. When we think of communication, we think of dialogue, and language. Language, according to Sapolsky is more than speaking or writing verbally. Neuroscience has indicated, especially through studying the neurobiology of sign language learning of completely deaf individuals, that whether it is verbal or non-verbal, the communication process is the same. This means that language is not merely a motoric process (i.e. about moving lips and tongue), but rather a cognitive process.

Language is unique to humans

Human communication has universal qualities. All forms of human languages have semanticity, embedded clauses, all human language can “talk about things”, can talk strategy. There is arbitrariness of language, in which words are not tied to meaning. People are able to tell lies, and say one thing and mean/feel another. Language is also invented and re-invented. Human children have innate ability to coin phrases and say things they have never heard before (N. Chompsky).

Unlike animals that have specific vocals for specific emotions, human language is not tied to specific emotions. This explains why in therapy we notice a quality of communication in which there is a “content-affect split”.

Non-verbal aspect of language

We do not communicate with words alone, there is also verbal tone, sounds, body movement, hand gestures, facial expression. Gestalt therapists look out for these during therapy as well, since the non-verbal language reveal often much of the emotional content of the communication. Certainly emailing does not allow for non-verbal communication. Perhaps that is why many of us feel more secure communication over messenger apps to even talking on the phone.

Neuro-centers of the brain that affect language

Ninety percent of humans process verbal language in the left hemisphere of the brain. The other (right) hemisphere, process the non-verbal and emotional content of the communication. The Broca’s area is connected to the motoric nature of language production. The Wernicke’s center is responsible for language comprehensibility. The connection between these two centers connect the two functions.

Through studies of biological brain disfunction due to disease, degeneration or injury, scientists have managed to identify which part of the brain is utilized for which function. Through neuro-imaging, we know that in tourettes syndrome, for example, where the sufferer curses uncontrollably, the limbic system is hyperactive. The limbic system is not known to be responsible for emotions and not language production, but language is connected to the formation of emotions.

Many have also proven that singing is a way for people who suffer damage to the Broca’s area (and hence have problems talking). Singing activates the right hemisphere and emotional centers of the brain.

Hence the phenomenon of the talking cure; an emotional weight off the shoulders when on talks emotionally to someone who is willing to listen.  One can also see how verbal language is only a part of communication. Clients who have problems with speech (in particular in Alzheimers patients) respond to communication with music.




Freud, S., & Breuer, J. (1895). Studies on Hysteria. SE 2.

When to Engage the Services of a Psychotherapist

When is it a good time to decide to get psychotherapy? What has to happen before someone actually needs psychotherapy? Does seeing a therapist mean that I am sick / crazy?

Nobody has to ask these questions when one is physically ill. One goes directly to the general practitioner, because it is clear to one that his/her body is not feeling as good as it normally does. Psychological health is slightly different, the degree of suffering is not so clear, and often we feel “it is not necessary” or “I can get through this” and/or “it is to much of a luxury” to get psychotherapy. Oftentimes ignored emotional challenges (which can be unpacked in psychotherapy) lead to debilitating mental suffering in later life.


Certainly this article come from within a psychotherapist’s blog. It is however the intention of the author to shed light on the “hows”, “whys” and “what for” in seeking psychotherapeutic treatment. As a psychotherapist having worked also in psychiatric wards in hospitals, I’m also a witness to how mental health of an individual today is vulnerable to life-changing situations.

Individuals who attend therapy when they can still work and function in their daily lives have better prognosis than those who are at already a point where their psychological state does not allow them to live independently of others or medication.

When is appropriate time to seek psychotherapy?

Imagine these rather normal scenarios:

Scenario 1: Your child is not sleeping well, and has frequent nightmares. In the day he is agitated and has problem paying attention. This is stressful for you, because you are at a loss in managing his fits of anxiety, crying at night, etc. You are thinking of seeing the pediatrician/child psychiatrist but he/she is a doctor, and you are aware of the side effects of prescription drugs on children.

Scenario 2: You lost a parent 2 years ago and most of your family members and yourself have mourned your loss and have moved on. Your youngest sister, 15, is lately very depressed and has stopped going to work or socializing. You believe that she has not got over the loss of the parent.

Scenario 3: You are aware that you are using the computer / smartphone / tablet constantly. It is difficult for you to get yourself away from the LCD screen. When you’re in social events and have to turn off your phone, you feel annoyed and want to leave the place. You have feelings of guilt/shame about this.

Scenario 4: You are a successful career person. Lately you have not slept for more than 4 hours on average per night. You’re mentally exhausted, but every night you lay in bed, and your mind is racing with thoughts. You are considering taking sleeping medication.

Scenario 5: You are a college student and have recently moved out of your family home. Lately you have been feeling panic attacks in the night.

Scenario 6: Your child has been diagnosed with an illness that requires complicated medical treatment. You are worried sick. You have other children.

Scenario 7: You witnessed something traumatic (real or fiction or imagined). 6 months later, you still get nightmares and/or flashbacks.

Scenario 8: Your teenager is withdrawing from the family and his/her grades, which used to be good, are falling.  You notice him/her losing excessive weight. You need someone to talk to.

Scenario 9: You are suffering pain in part(s) of your body, and the many doctors you have consulted confirm that they could find no physical clues to the causes. Doctors tell you it could be psychosomatic.

Scenario 10: Your marriage is breaking up, and you are worried that the children will be affected by the split. You want to get a divorce and you want the process to be done cordially, so that the children are spared the emotional turmoil involved in the conflict.

In all these scenarios, the services of a qualified psychotherapist can be a life-saver. These problems are not uncommon, and they happen to anyone living in this internet age we are in today. It is not to say that the internet per se has anything to do with it, but these are the kinds of problems familiar to people around the world.

What Happens in Psychotherapy?

A psychotherapist is a professional trained to be a person-in-contact with you and/or your child. As human beings we get embroiled in our daily life, unawares of the underlying emotions that drive us. These un-felt, emotions are what some of us would describe as the unconscious.

The therapist’s work is to study this aspect of your character.  He/she does this by asking you questions about yourself, and checks with you at each step how you feel about certain things. The therapists also gives you feedback on your blind spots about your mannerisms, incongruences in your dialogue with him/her (for example if you contradict yourself or if your words  contradict your body language, etc). The therapists holds a dialogue with you in this way and in so doing, you discover things about yourself you were not previously aware of. You also gain insights into the the situations you found yourself “stuck” in.

Above all, psychotherapists work under the rule of strict confidentiality.

Difference between psychotherapists and counselors

Psychotherapists, more so than counselors, work with your unconscious.  We are interested in what drives and motivates you, and what is causing the stress responses in your lives. Psychotherapists that work with couples and families treat the individuals as part of a system. It is the unconscious forces in each member of the family that create the family dynamics. Psychotherapists believe that it is only by going deep into the emotions can we really uproot the inner conflicts behind the stress, sleeplessness, psychosomatic pain and problems that we face in our daily lives.

Most psychotherapists, unlike counselors, do not give advise (at least they try not to). Rather, the therapist will sit with you during these hours and provide you just enough support and as much support as you need to find your own resources. This way, we do not heal you, we help you make your own reparations.

Difference between psychotherapists and psychiatrists

Most Psychotherapists, unlike psychiatrists, spend more time being with you and we do not provide psycho-pharmaceutical drugs. If you are depressed, we provide do not encourage you to reach for an antidepressant (sometimes we send clients to the psychiatrist, when the client’s symptoms are severe). If you are on medication, we would ask you how it is working for you. Some clients come to us because they want to wean themselves off the drugs. This is because many psycho-pharmaceuticals are dangerous if you suddenly stop taking them.

Gestalt therapists, for example, works as your person in contact, who would guide you through your inner conflicts (which we know can feel desperate), and walk you through the experiences till you see the light again. Usually we expect to go through with you some painful experiences, thoughts and memories. We believe that it is through understanding these anxiety-causing experiences that you can find long-term peace to live again. Taking medicine alone robs you of this chance to overcome your depression in this way.

Difference between psychotherapists and psychologists

Unlike clinical psychologists, psychotherapists view the client as an individual person, builds a transpersonal relationship with you, and do not commonly see diagnosis as a main part of their work. This means that we do not see you as “a depressed patient”. We regard you as a person in relation to us who is in a mental / spiritual / emotional / social / relational situation that needs to be understood. Psychotherapists delve into the unconscious inner conflicts, looking at childhood experience and past traumatic events /illnesses that may be the cause of present afflictions. He/she sees the client as an individual with a special challenging life situation, with a unique family background, with a unique vulnerability. Most psychotherapists are trained to contain your vulnerability.

How do Psychotherapists do this?

Most licensed psychotherapists from Austria & Germany ( I can only speak for this part of the world since I am trained there) are rigorously trained for the profession. The training takes more than 6 years to complete. We are trained academically in psychology, psychopharmacology, sociology, gerontology, child and youth psychiatry, psychotherapy research, cultural anthropology, philosophy, neuroscience, ethics, sexuality and diagnostics. Over and above the academic studies we complete hundreds of hours of individual psychotherapy and group psychotherapy ourselves. We also work at least a thousand hours in psychosocial and hospital institution as interns.

How do you shop for a psychotherapist?

Use the internet and check their credentials. Psychotherapists who do not have credentials little accountability. Since you are engaging someone who is going to work with your mental suffering, it is only advisable to engage someone who is trained in a reputable institute.

Call the therapist and ask for a first interview. During this interview ask questions and you’ll have a feel if this person can help you. After a few sessions, check again.

Recommendations from friends/and other professionals do help. The best is to try the therapist out.

Characteristics of therapist to look out for:

  • does he/she answer your questions transparently?
  • do you get the impression that your concerns are being addressed?
  • do you get the impression that he/she is authentic in what he/she says?
  • do you get the impression that he/she is curious about you?

Most important thing to remember is that the therapist is a professional to serve you. In your first interview with him/her you should get impression that the therapist is more interested in knowing about you than about him/her telling you about him/herself.




Psychotherapy is about Uncovering Truths of the Self

It is said that the truth will set you free. In psychotherapy patients liberate from the psychological stressors in their lives through uncovering the truths about themselves.

This might sound counterintuitive if we believe that we know everything about ourselves or that we are in total control of the decisions we make. The field of psychology has proven empirically that this is not the case, and psychoanalysis has provided theories about how this is so.

Put briefly, the human person is an integral part of his/her society and culture through which our  psychological processes are influenced.

Knowing the truth is coming to terms with this realization. That we become depressed, anxious, angry… etc because we have lost the sense of our of needs. In so doing we turn them into symptoms, so that we do not have to face these needs.

An example would be that of a woman who is depressed and no longer able to enjoy simple things in life. Through therapy she uncovers the truth that her going into depression is a means for her to not face up to an inner rage, for it was safer to lock oneself into a state of depression than to attack another person, especially an abusive childhood caregiver.  Realizing the truth of her rage, she is able to talk about it and understand it. In Gestalt therapy, the client is encouraged to express this rage through art, speaking, acting out, writing… etc. When the underlying issue is set free, the depressive symptoms lose their foundation as well.

Therapy in this way is done with the patient being in control of his/her progress. Therapists in general do not advice, coerce or make analysis to tell the clients what the truth is. Clients find this out through dialogue with the therapist. The client has the agency to his/her own truths and healing.

When patients are asked retrospectively what they gained from a period of psychotherapy, their answers frequently feature an increase in their sense of agency: “I learned to trust my feelings and live my life with less guilt,” or “I got better at setting limits on people who were taking advantage of my tendency to comply,” or “I learned to say what I feel and let others know what I want,” or “I resolved the ambivalence that had been paralyzing me,” or “I overcame my addiction” are typical comments (McWilliams 1990 p. 16).


McWilliams, N. (1999). Psychoanalytic case formulation. Guilford Press.

Symptom Relief in Psychotherapy

It is a given that a person comes to therapy to seek relief in symptoms  psychological stress, relationship tensions and/or physical pain/discomfort not treatable by medicine alone. Usually a patient comes to a therapist to present a problem or a chief complaint after having suffered it for a considerable amount of time, while trying alternative/self-treatments.

It is not unusual that the decision to come for psychotherapy and the meeting of the therapist alone can diminish the symptoms. This is due to the relief the client usually feels after having let go of the need to control his/her own symptoms.

Despite this, psychotherapeutic treatment usually lasts months and often years. This is because as the therapy progresses the client and therapist uncover areas underlying the symptoms that need to be addressed, along the way setting new therapeutic goals. The work of therapy goes beyond the swift removal of  disturbances.

Uncovering root causes of symptoms are often painful processes. The client needs to feel safe and trust the therapist enough to go deep into the work. For example a young woman with anorexia comes to terms with her feelings of betrayal and entrapment within a perfectionistic family only after 6 month in treatment. She needed another year to come to terms with inner rage against her care givers in order to overcome feelings of disgust for having food in her stomach.

 Other examples include the man who comes for short- term couple therapy to “improve his communication” with his wife turns out to have a secret lover who is rearing his unacknowledged child; or the little boy referred for “acting up” with authorities has a private habit of torturing small animals (McWilliams 1999).

Clients usually need a lot of time in order to have the courage to open up their most painful emotional experiences– first to themselves, than to the therapist. Through the trust built within the therapeutic alliance, can revelations of negative emotions like fears and shame be grasped. Through coming to terms with these feelings of vulnerability can the client learn to master his/her feelings and behavior with understanding, knowing that he/she has choices and has the capacity to reach for resources.


The man who is compulsively unfaithful to his partner wants not just to stop having affairs but to be relieved of his constant preoccupation with fantasies about them. The woman with an eating disorder wants not just to stop vomiting but to get to the point where food is merely food to her, not a repository of desperate temptation and wretched self-loathing. A man or woman who was sexually abused in childhood wants to change internally, subjectively, from feeling like a sexual abuse victim who happens to be a person to a person who happens to have been a sexual abuse victim (Frawley-O’Dea, 1996).

Psychological symptoms (and psychosomatic symptoms as well) are the result of an individual’s survival strategy, otherwise known as creative adjustment to unpleasant experiences usually encountered in childhood. Hence the problems clients come to the therapists with,( e.g eating disorders, panic attacks, depression, relationship problems, addictions… ) are superficial signs (or tip of the iceberg). Looking at the experiences and emotions that lie within to keep these symptoms going is what the therapy is about. It is through uncovering these that the client gets to fully understand the root of his/her symptoms, and gradually find their own resources to relieve themselves of the effects of these symptoms and live better.


McWilliams, N. (1999). Psychoanalytic case formulation. Guilford Press.

What can Psychotherapy do for you?

The questions “what is psychotherapy for?”, “what is the benefit of psychotherapy to the client?” “what should I expect from seeing a psychotherapist?” can be summarized as questions to seek out the goals of psychotherapy.

Setting Goals are Necessary in Therapy

Psychotherapy research has shown that goal setting on the onset of psychotherapy treatment is instrumental in the outcome of the therapy. This may seem the obvious course of action and “something all therapists and clients do”. However, if we think setting therapy goals is straight-forward, it could be that we are not setting the goals conscientiously enough.

Difference between Psychotherapeutic Diagnosis and Medical Diagnosis

Somewhat like a patient going to a doctor’s office, the client goes to a psychotherapist because he/she is facing discomfort and/or is suffering from symptoms. Unlike the doctor’s patient, the psychotherapeutic client’s symptoms are of a psychological nature. This is where we have to be more conscientious than the doctor.

Each Client is Unique

Psychological pain is multifaceted and is not realistically diagnosed on the spot. Therapists use questionnaires and their own observations as instruments for diagnosis, but we are also aware that what we see in the client is unique to the client.  This is largely due to the understanding that psychological suffering has much to do with the client’s environmental situation (social, economic, historical, etc.) as well as the client physical state. Most of these factors cannot be tested using test kits. These get uncovered through therapist-client dialogues in the therapy session.

Goals in Psychotherapy that Benefit Clients

Goals made between client and therapists that go beyond merely “fixing symptoms” do more justice to, and offer more benefits to the client. This is especially important for client who have dependency or non-functioning behavioral issues.

McWIlliams (1999) writes quite clearly that the goals of psychotherapy extends beyond the disappearance or mitigation of symptoms of psychopathology. It extends also to

  • * the development of in- sight, an increase in one’s sense of agency,
  • * the securing or solidifying of a sense of identity,
  • * an increase in realistically based self-esteem, an
  • * improvement in the ability to recognize and handle feelings,
  • * the enhancement of ego strength and self-cohesion,
  • * an expansion of the capacity to love, to work, and to depend appropriately on others, and
  • * an increase in the one’s experience of pleasure and serenity.

There is empirical evidence to prove that when these goals are worked on, positive changes happen, including better physical health and greater resistance to stress (p.12).


McWilliams, N. (1999). Psychoanalytic case formulation. Guilford Press.

Former patients’ conceptions of successful psychotherapy

This article features a study by Binder et. al 2009,  Why did I change when I went to therapy? A qualitative analysis of former patients’ conceptions of successful psychotherapy. 

The findings of this study provides us with some answers to what patients or clients of psychotherapy regard as change in psychotherapy, and how they perceive their experience in therapy which is considered successful for them.

The client’s point of view is very important. Mental states cannot be fully measured, as opposed to physical states. There is no machine, or test kit to measure the mental state of health. A person’s mental wellness is witnessed through his/her ability to function in daily life, and also his/her own perception of how things are.

What is successful psychotherapy or counseling? If a client claims to feel better, we’d ask what they meant. It could mean they feel more relaxed, less stress, less anxiety.  They could say that they are able to sleep better, have less physical pain. Or they could feel more energetic– whichever is important to the client at the time.

Methodology of this Study

The qualitative research was conducted using semi-structured, qualitative, in-depth interviews with 10 former psychotherapy patients, recruited through an advertisement in a local newspaper. A descriptive and hermeneutically modified phenomenological approach– i.e. using expert interviewing and not just questionnaires in order to grasp full meaning of what is transpired in conversation –was used to analyze interview transcripts.


What was most important explicitly for the clients in the therapy?

1  Having a relationship to a wise, warm and competent professional.

  • the client’s feeling of safety within the therapeutic relationship was mention.
  • the therapist having the right doses of contact with the client, and
  • the therapist having flexibility in approach to working with the client.

2  Having a relationship with continuity, safety and hope when feeling inner discontinuity.

  • the continuity, consistency of the therapy.
  • therapist being with them through difficult emotional experiences.

3  Having beliefs about oneself and one’s relational world corrected.

  • the patient is able through therapy to reconnect with his/her meaning making, having a look at misconceptions or introjects of which the client was not aware of.
  • therapists guides the client through his change of the worldview.

4  Creating new meaning and see new connections in life patterns.

  • the idea of having been helped by having one’s beliefs and belief systems corrected,
  • help in making new choices, or change in habitual patterns
  • helps the client see how the his/her present experiences and behavior in reaction to the experiences are rooted in the past experiences, i.e getting clarity and insight.


Psychotherapy is quite unlike medicine. The clients’ or patients’ needs for treatment are very diverse and individual. Even though there is such a thing as diagnostics in psychiatry, we have to understand that these diagnostics are constructs for professionals to communicate the symptom of the client with each other. With psychological issues, the same symptom displayed may does not mean same source or cause of problem. It also does not mean that the clients with same symptoms will benefit from similar treatment.

Why this?

Put simply, it is because the mental state of the individual is the product of the individual’s relationships, culture, physical health, age, economic situation… etc. The psychotherapist sees the client as a whole person, whose experiences and meaning making are important in therapy.

The result of the findings reflect this.


Binder, P. E., Holgersen, H., & Nielsen, G. H. (2009). Why did I change when I went to therapy? A qualitative analysis of former patients’ conceptions of successful psychotherapy. Counselling and Psychotherapy Research9(4), 250-256.

Psychotherapy expertise in Singapore: A qualitative investigation

These are summarized findings obtained from this 2008 study by Jennings et. al. entitled Psychotherapy expertise in Singapore: A qualitative investigation. The researcher cited Singapore as a good place for studying psychotherapy due to it cultural diversity relative to its geographical size.

In this study, a group of 9 therapists and/or counselors were selected from a pool based on being seconded by colleagues as “master therapists”. The interviews were conducted with structured questions, and video-taped. These were later analyzed using grounded theory.

Results of the Study

Here are the viewpoints of the master therapists.

Needed personal characteristics that therapists should have:

  • Empathic : Master therapists spoke of possessing a great empathy for their clients. As one master therapist explained, once the client felt genuinely understood and accepted in whatever circumstances, true change and healing began.
  • Non-judgmental:  This trait can produce a sense of safety for clients.
  • Respectful: The master therapists were mindful of their impact on clients and the importance of working with clients in a respectful manner. Respect for clients, whoever they are and whatever their issues may be, was a pervasive theme among these master therapists.

Needed developmental influences that therapists should have are:

  • Experience: The interviewees described a journey, explaining the many elements that created and influenced their path to expertise. When exploring elements of expertise, experience was mentioned frequently as an important factor. One master therapist made the point that there were no quick developmental influences and no guarantee that experience alone leads to expertise.
  • Self-awareness: The master therapists spoke of how their self-awareness has served them well when conducting therapy. One master described it as recognizing your internal processes when working with clients and being able to be a participant/ observer of interactions with clients.
  • Humility. The master therapists recognized humility as another important component in the development of expertise. Recognizing one’s limits may serve as a source of motivation and growth. One master therapist described the importance of the humbling process of recognizing and learning from one’s mistakes.
  • Self-doubt: Despite their experience and reputation, some of the master therapists addressed another issue related to the development of expertise* periodic self-doubt*and how this feeling motivated them to keep growing their clinical skills.

Therapists’ approach to practice:

  • Balance between support and challenge: Many of the master therapists spoke of the importance of maintaining a balance between support and challenge when working with clients.
  • Flexible therapeutic stance. The master therapists described a flexible approach in their work with Psychotherapy clients. If client variables required them to adapt their style, they did. One theory does not fit all.
  • Empowerment/strength-based approach: A number of master therapists spoke about their clients’ internal resources and how the therapist’s task was to reinforce these strengths and bring them to bear in dealing with the problem at hand.
  • Primacy of the therapeutic alliance: Many of the master therapists acknowledged the importance of the therapeutic relationship. The impact of the relationship varied from a necessary condition in the therapeutic process to the relationship being the actual source of healing.
  • Comfortable addressing spirituality: Beyond observance of any particular religion, many master therapists spoke of a broad personal spiritual mind-set, which primarily functioned as a backdrop when working with clients but also included some therapists privately praying for clients.
  • Embraces working within a multicultural context: A number of master therapists spoke of the importance of cultural awareness in their work and the challenges of adapting Western therapeutic approaches to Eastern values and systems.

On on-going professional growth:

  • Professional development practices: Professional development, a key factor in developing and maintaining expertise, was not limited to conferences, literature, or textbooks. One master therapist believed that therapists should extend beyond their areas of practice to broaden development.
  • Benefits of teaching/training others: Now highly regarded and seasoned, the master therapists have much to offer other therapists. Many of the master therapists viewed teaching and training as an opportunity to hone their own skills and to reflect upon their practice.
  • Challenges to professional development in Singapore. During the interviews, master therapists identified several ‘‘professional growth edges’’ in the Singapore psychotherapy profession. For instance, a training need recognized by several therapists was that of basic counseling skills. One master therapist explained that basic counseling skills are not natural for many Singaporean trainees.


Comments on the Study and it’s Results

As a Singaporean therapist with training in Austria, it appears that what the master therapists highlight regarding personal characteristics, development and education of therapists are not so different in Singapore than in Europe.

There is one difference that stands out for me, and that is of the need of the Singapore-based therapist to address spirituality. Although it is also important in Europe, the emphasis in this article gives me the impression that is more important and challenging in Singapore.

What is somewhat disappointing about the results is that (and it was articulate also in the article) is that the Master therapists shared very little of their own emotional experiences. The researchers attributed it to the cultural background of the therapist. As someone doing qualitative research myself, I am of the opinion the it is the job of the researchers to lead the subjects to provide this information.

It could be that the shortfall in this study is the interviewers own discomfort in checking with the interviewees on more personal levels.

As a whole, I do agree that Singapore is good ground for psychotherapy research.


Jennings, L., D’Rozario, V., Goh, M., Sovereign, A., Brogger, M., & Skovholt, T. (2008). Psychotherapy expertise in Singapore: A qualitative investigation. Psychotherapy research18(5), 508-522.

Projective Identification

Otto Kernberg explains what Projective Identification is:

Projective Identification is one of the primitive defensive operations that goes together with splitting and primitive idealization and omnipotent control.

It is a primitive form of projection of attributing to others what one cannot tolerate in oneself. It is characterized by combination of attributing to somebody else what the person is experiencing but cannot tolerate. While they are still capable of maintaining empathy of what they experience but cannot tolerate. There is also a tendency to induce behavior in the other in effort to control the other person to absolve themselves.

Basically it is an insidious method of inciting emotions, which one cannot come to terms with in oneself, in another person. This as a means to control the other person. 

A possible example of such an occurrence is someone who is insecure and envious of another. This person creates situations whereby he/she incites envy and/or competition in the other person.

It could also someone controlling a group. A manager may have a paranoid ideas of the team being disloyal to him, begins to behave in ways to incite feelings of mistrust between the members of the company.


Extra Notes (see Video attached) on Child abuse and projective identification:

Identification of the aggressor : being a ghost to chase the ghost away, stockholm syndrom (Anna Freud’s).  Ferenczi’s idea of identification with the aggressor: The abused child behaves in the way the abuser wants to protect himself from the abuser, by appeasing and complying.

The child introjects the abuser’s feelings: he feels both innocent and guilty. There is a clash of feelings. The abuser, to make himself feel less guilty induces the guilt on the child victim. The parent / abuser projects the impart feelings (also known as projective identification, a term Melanie Klein coined later on) on the child. He induces guilt on the child. The child introjects the shame and feels guilty.

The client should be allowed to express their criticism on the therapist, or they will turn on themselves. These negative feelings are not just negative transference. When the clients can voice their critic in therapy, it is a breakthrough. It is a break from the childhood pattern.


Moments of Uncertainty in Therapeutic Practice: Interpreting Within the Matrix of Projective Identification, Countertransference, and Enactment

Projective and Introjective Identification and the Use of the Therapist’s Self (The Library of Object Relations)

Projective Identification: The Fate of a Concept (The New Library of Psychoanalysis)

Projective Identification and Psychotherapeutic Technique