Professional boundaries in the physician-patient relationship.
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Communication↗
Biomedical subjects
G O Gabbard
Publications and source records attributed to G O Gabbard.
Can patients sexually harass their physicians?
It is the fate of certain fashionable legal terms that capture the attention of the media to have their usage expanded beyond the contexts for which they were originally designed. Such is the case with the term sexual harassment. Essentially, it describes situations in which a powerful person attempts to influence an individual's economic or academic status based on his or her response to sexual comments or behaviors. Title VII and Title IX of the US Code contain federal laws that prohibit discrimination based on sex in the workplace and in the education system, respectively. Accordingly, sexual harassment that occurs within the context of the employment or academic arena is prohibited under Title VII and Title IX and has evolved to apply to hostile work or academic environments that do not per se influence an individual's economic or academic status.
Female↗
Erotic transference in the male adolescent-female analyst dyad.
Erotic transference involving female analysts and adult male patients has received increased attention in the past ten years. Absent from the literature, however, are any clinical reports concerning erotic transferences of adolescent male patients with female therapists. This paper presents a fragment of a treatment involving an adolescent male patient who developed an erotic transference. The vicissitudes of the transference, as well as his relationship to his mother and father, are discussed from the perspective of developmental conflicts and tasks of adolescence. The countertransference dimensions of this particular gender constellation are also examined from the standpoint of intrapsychic and cultural factors.
Adolescent↗
Countertransference: the emerging common ground.
In the last decade or so, the understanding of countertransference has become an emerging area of common ground among psychoanalysts of diverse theoretical perspectives. This convergence can be traced to the development of two key concepts--projective identification and countertransference enactment. Projective identification has evolved from a patient's intrapsychic fantasy in Klein's original work to an interpersonal interaction between patient and analyst. The notion of countertransference enactment has been widely used to capture clinical situations in which a countertransference reaction in the analyst corresponds to the patient's attempt to actualise a transference fantasy. These ideas, in conjunction with the contributions of social constructivists and relational theorists, as well as Sandler's conceptualisation of role-responsiveness, have led to an understanding of countertransference as a 'joint creation' by analyst and patient. The relative contributions of analyst and patient vary somewhat according to the theoretical perspective espoused by the analyst. This common ground is best regarded as comprising a gradient or continuum in which more weight is given to the analyst's contribution on one end of the continuum and more emphasis to the patient's contribution on the other. While countertransference enactments are widely regarded as inevitable, their role in creating intrapsychic change is more controversial.
Countertransference↗
The role of mother-son incest in the pathogenesis of narcissistic personality disorder.
Psychoanalytic case material is presented to illustrate how mother-son incest may be involved in the pathogenesis of a particular subtype of narcissistic personality disorder. Male patients with this disorder have a grandiose view of themselves as entitled to occupy a special position with others, combined with a paranoid tendency to anticipate imminent betrayal. The enormous guilt related to perceived oedipal transgressions leads these patients to fear retaliation from an enraged, vindictive, and castrating father at any moment. In addition, these men often feel that their special role vis-à-vis mother is a precarious one contingent on doing her bidding. Hence, they also live in dread of an impending disaster involving either abandonment or humiliation by their mothers.
Adult↗
On love and lust in erotic transference.
Intense erotic transference is one of the most powerful and challenging phenomena in clinical psychoanalysis. Powerful longings for love and for sexual gratification are likely to elicit enactments in the analytic setting that interfere with the analyst's ability to maintain a dual state of awareness in which he or she is both a participant in and an observer of the immediate experience with the patient. These enactments occur on a continuum from frank love affairs between patient and analyst to subtle forms of partial transference gratification. Moreover, the two primary elements in the manifest content of erotic transference--love and lust--may be dissociated from one another and may produce significantly different reactions in the analyst.
Adult↗
Mind and brain in psychiatric treatment.
Psychological and biological components of psychiatric illness must be integrated to avoid the perils of reductionism in diagnosis and treatment. With the decline of dualism, a number of creative thinkers have conceptualized the mind-body problem in a manner that values perspectives derived from psychoanalytic thinking as well as from the neurosciences. Similarly, modern studies of the etiology and pathogenesis of major psychiatric disorders suggest that only through a sophisticated synthesis of psychosocial and genetic/biochemical points of view can causation be comprehensively understood. In light of this accumulating knowledge, the author concludes that treatment must be informed by psychotherapeutic approaches as well as by pharmacotherapy.
Adult↗
Psychotherapists who transgress sexual boundaries with patients.
The causes of therapist-patient sex are complex and multidetermined. Efforts to understand why psychotherapists transgress sexual boundaries are hampered by the lure of reductionism and oversimplification. Most of those who examine this issue would prefer to categorize all such therapists as "bad" and "corrupt" as away of distancing themselves and disavowing any similarities between these therapists and themselves. The pathology of therapists who commit sexual boundary violations generally falls into four broad categories: (1) psychotic disorders, (2) predatory psychopathy and paraphilias, (3) lovesickness, and (4) masochistic surrender. Although a variety of individual psychodynamic factors are involved within each group, this classification is highly useful for informed treatment planning.
Female↗
Sexual excitement and countertransference love in the analyst.
The psychoanalytic literature has been remarkably silent on the subject of erotic countertransference feelings. The recent emphasis on transference-countertransference enactments in the analytic setting has resulted in increased openness about development of such feelings. Several key themes appear to be involved in the analyst's sexual excitement, including loss of the "as-if" nature of transference and countertransference, a measure of hostility and contempt, the perception of a deficit state in the patient, a defense against loss and mourning, and oedipal and preoedipal enactments involving a variety of gender configurations. These themes are illustrated with clinical material. The differences between those analysts who contain and constructively process erotic countertransference and those who destructively act it out are also discussed. The crucial role of consultation with a colleague is emphasized as a valuable recourse.
Countertransference↗
Treatment of borderline patients in a multiple-treater setting.
For all the problems and challenges inherent in a multiple-treater setting, there are great advantages in being part of a treatment team. Colleagues provide a holding and containing function for each other in the treatment of these extraordinarily difficult patients. Marcus observed that "the problem with the sickest patients is that the affects are uncontainable by a single individual. The affects are more easily containable by the group, because at any one moment some members are not under direct threat and, therefore, can maintain an observing ego" (p 251). The different treatment relationships offer the borderline patient numerous opportunities to internalize new modes of object relatedness through the process of reintrojecting what they have projected into others. The cumulative effect of a group of caring professionals who are doing their best to process and understand what is happening can be highly therapeutic.
Borderline Personality Disorder↗
Psychotherapists who transgress sexual boundaries with patients.
The causes of therapist-patient sex are complex and multidetermined. Efforts to understand why psychotherapists transgress sexual boundaries are hampered by the lure of reductionism and oversimplification. Most of those who examine this issue would prefer to categorize all such therapists as "bad" and "corrupt" as a way of distancing themselves and disavowing any similarities between these therapists and themselves. The pathology of therapists who commit sexual boundary violations generally falls into four broad categories: (1) psychotic disorders, (2) predatory psychopathy and paraphilias, (3) lovesickness, and (4) masochistic surrender. Although a variety of individual psychodynamic factors are involved within each group, this classification is highly useful for informed treatment planning.
Antisocial Personality Disorder↗
Psychotherapist-patient sexual contact after termination of treatment.
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Adult↗
Psychodynamic psychiatry in the "decade of the brain".
OBJECTIVE AND METHOD: To illustrate the continued relevance of psychodynamic thinking in the practice of contemporary psychiatry, the author reviews a number of studies that demonstrate the intimate connection between psychosocial and neurophysiological factors in the etiology and pathogenesis of psychiatric disorders. A survey of three specific anxiety disorders illustrates the complex interaction between mind and brain in these disorders. RESULTS: Research on both primates and humans suggests that psychological influences result in permanent alterations of a neurobiological nature. Similarly, psychological interventions in a treatment context may have a profound impact on neurophysiology. Clinical case examples demonstrate that "biologically based" disorders may be rich in unconscious meaning. Clinical understanding of the meaning of symptoms may be instrumental in ensuring patients' compliance with pharmacotherapy regimens and in the removal of other resistances to treatment. CONCLUSIONS: In contemporary psychiatry, a psychodynamic perspective must be preserved. Without it, meaning will be lost, and both diagnostic understanding and informed treatment planning will suffer as a result.
Adult↗
Obstacles to the dynamic understanding of therapist-patient sexual relations.
Several dynamic resistances appear to interfere with rational and empirically based discourse about therapist-patient sexual misconduct. These resistances include the lure of reductionism and a longing for simplicity; wishes for "political correctness"; gender bias; and confusion about the nature of the trauma in sexual misconduct. We conclude that (1) empirical study may produce unpleasant results; (2) "politically incorrect" models of misconduct merit study with care equal to "politically correct" ones; and (3) those reenactments we call transference-countertransference should be viewed in all their human complexity. Only then will our increased understanding of misconduct offer hope of prevention.
Ethics, Professional↗
The therapeutic relationship in psychiatric hospital treatment.
The therapeutic relationship between staff members and patients is a crucial healing ingredient of psychoanalytically informed hospital treatment. The author describes how this relationship facilitates each patient's repetition of early object relations, which are reenacted with staff members through splitting and projective identification. During regular meetings, staff members work together to understand and integrate the various projected parts of a patient's psyche, which are then reintrojected by the patient through both interpretive and noninterpretive aspects of the therapeutic relationship. The author concludes by describing the deleterious effects on this process of current economic and regulatory forces.
Adult↗
Psychodynamics of panic disorder and social phobia.
d psychological treatments of psychiatric disorders are often wrongly polarized. The related anxiety disorders, panic disorder and social phobia, illustrate the interdependence of biology and psychology. The author describes current psychodynamic understanding of the factors that contribute to the etiology and pathogenesis of these disorders. He concludes by stressing the value of integrated, psychodynamic treatment.
Behavior Therapy↗
A psychodynamic perspective on the clinical impact of insurance review.
The rise of managed care and concurrent utilization review has had a profound impact on the practice of inpatient psychiatry. Little has been written, however, on the clinical impact of the review process itself. The actions of insurance reviewers often result in their being incorporated into the psychopathology of individual patients and into the dynamics of families and institutional settings. The authors apply psychodynamic understanding to a series of case examples to illustrate how concurrent review may promote splitting, impede the patient's ability to separate from the hospital, and paradoxically reinforce the patient's illness. They also explore a number of typical responses of treatment staff and families to the review process. A case vignette demonstrating a sincere effort at mutual collaboration between payers and providers is also presented. This spirit of compromise is proposed as the solution that best serves patient care.
Adolescent↗
Homicidal maniacs and narcissistic parasites: stigmatization of mentally ill persons in the movies.
The portrayal of mentally ill persons in movies and television programs has an important and underestimated influence on public perceptions of their condition and care. Movie stereotypes that contribute to the stigmatization of mentally ill persons include the mental patient as rebellious free spirit, homicidal maniac, seductress, enlightened member of society, narcissistic parasite, and zoo specimen. The authors suggest that mental health professionals can fight this source of stigma by increasing their collaboration with patient advocacy groups in monitoring negative portrayals of mentally ill people, using public information campaigns such as Mental Illness Awareness Week to call attention to the process of stigmatization, and supporting accurate dramatic and documentary depictions of mental illness.
Attitude of Health Personnel↗