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Adolescent suicide: an overview.

Etiological theories of suicide are reviewed from epidemiological, individual (both biological and psychological), and psychosocial perspectives. Cohort and population-model approaches as explanations for the two- to three-fold increase in completed suicide rates observed in adolescents and young adults over the past 25 years are presented. The results of the authors' study of suicides in adolescents and young adults in Cuyahoga County, Ohio, to test these hypotheses are summarized. This study revealed marked cohort differences in suicide rates and provided partial support for the "population-model" approach. Differences between suicide rates in adolescents and other age groups are discussed, as are data from some minority groups. The role of depression in adolescents and various studies of diagnostic approaches (e.g., structured diagnostic assessments, biological markers, clues during intensive psychotherapy or psychoanalysis, studies of high-risk diagnostic groups) are reviewed. Lastly, treatment employing individual, family, and group approaches to classical psychoanalytic or cognitive psychotherapy as well as the role of pharmacological treatments are considered.

Adolescent↗

Portrait of a sadist as a young man.

Treatment of chronically violent patients poses problems for the therapist in a number of ways. Institutional demands, concern for one's personal safety, and psychotic transferences are common. This case details the treatment of one young violent offender.

Adolescent↗

Forensic sexology: paraphilic serial rape (biastophilia) and lust murder (erotophonophilia).

Forensic sexology is not synonymous with either forensic psychiatry or forensic psychology. It is a specialty in its own right, and is needed in the courtroom. Paraphilic sex offenders on trial are misrepresented as being, by their own choice, psychopathic or sociopathic deviates. They are unable to explain their paraphilic criminality to either themselves or society. In a case of serial rape and serial lust murder here presented, the contributory causes are examined and differentiated as hereditary predisposition, hormonal functioning; pathological relationships, sexual abuse; and syndrome overlap with bipolar disorder, schizoid disorder, antisocial personality disorder, epilepsy, and multiple personality. The precipitating causes were differentiated as childhood head injuries, and adult head injury at age 20. Left impact trauma and sexological trauma were sequelae of the adult injury. The full range of diagnostic resources was not available for a prisoner on death row. Capital punishment has not prevented the reemergence in each new generation of serial rape and serial lust murder as an epidemiological, public health problem. Punishment is an ineffectual substitute for epidemiological research into cause, effect, and prevention.

Brain Damage, Chronic↗

Short-term psychoanalytic psychotherapy with obsessive preadolescents.

The phenomenological and psychodynamic differences between obsessive preadolescents and obsessive adults are pointed out. Case material shows how an effective therapeutic alliance on psychoanalytic lines can be established quite early with preadolescents. The therapy can be shortened mainly by opening up sexual subjects connected with the onset of puberty, and by working through the guilt engendered by the ambivalent relations this age group has with its parents.

Adolescent↗

The narcissistic function in obsessive-compulsive neurosis.

Freud's intrapersonal concept of anal-sadistic regression is set against the interpretation of obsessive-compulsive neurosis as a structural ego deficit. The interpersonal dimension that comes to the fore as a result of this, becomes clear if we focus on obsessive-compulsive behavioral disorder: Persons suffering from obsessive-compulsive neurosis lack the self-assessment factor. It needs another person as part of their own ego who accepts and supports them in their behavior. A clinical example illustrates this narcissistic function of compulsion together with the changes in the psychodynamic approach and resulting therapy. Against DSM-classification with the concept of obsessive-compulsive disorder, which contains an unspecific symptomatology that occurs both in neurosis, schizophrenia, melancholia, and organic psychosis, this article advocates the specific and differentiated concept of obsessive-compulsive neurosis.

Ego↗

Love in the therapeutic alliance.

Volumes have been written about the patient's love for the therapist, but there has been relatively little discussion of the therapist's love for the patient. In an attempt to create a theoretical and technical space for discussing the appropriateness and role of love in the therapeutic relationship, a revised concept of the therapeutic alliance is applied to provide technical guidelines and understanding of two kinds of love between patient and therapist, corresponding to two systems of self-esteem regulation: an open, reality-oriented system and a closed, sadomasochistic system organized according to omnipotent beliefs. Examples of the role of love through the phases of treatment illustrate the interrelationship of love and the accomplishment of therapeutic alliance tasks.

Adult↗

The thrall of the negative and how to analyze it.

From clinical material of patient-analyst pairs caught up in negativistic transference-countertransference enmeshment, the defensive functions of negativism are explored for both patient and analyst. Fascination with and dread of the negative intersect as patients struggle to avoid terrifying aspects of self and other. The analyst works to avoid being trapped in negativism within the dyad. Containing, metabolizing, and transforming the dyad's mutual destructiveness and mutual love enable analyst and patient to feel safer with both. How to play with the negative, to engage the patient in play at the intersection of destructive negativism and dangerous love, is described.

Affect↗

A fresh look at perversion.

The history of ideas about perversion is considered, along with an examination of whether the concept is clinically useful. Three cases of varying degrees of severity are presented, illustrating the clinical value of the concept in the analytic situation. All three cases are women, and the particular usefulness of the concept of perversion for women is noted. The place of aggression and the pleasure resulting from its expression are highlighted.

Adult↗

On love, dying together and Liebestod fantasies.

The study of the legend of Tristan and Iseult in terms of the multiple fantasies it might express adds to our understanding of the psychology of love. In a previous paper (1975), I delineated, via allusion to the Tristan legend, the romantic-erotic conditions sometimes involved in creativity. In this one, I have approached the question of love from the other direction and have tried to delineate the creative-adaptive conditions required for integrating the experiences of loving and being in love. The "High tale of love and death," the Liebestod fantasy realized, is still with us, but the happier ending may be a realistic, viable alternative.

Fantasy↗

Fear of humiliation.

This paper explores the ontogeny of fear of humiliation, conceived of as an important organizing affect-laden fantasy in certain narcissistic personality disorders. The influence of the pleasure of the parental object in sadistically humiliating is emphasized in the overdetermined genesis of this fear. While, in elaboration of Loewenstein's (1957) and Eidelberg's (1959) contributions, "seduction of the humiliator" is a fundamental defensive process observed in masochistic characters, identification with the humiliator is a sadonarcissistic defense observed in work with certain narcissistic personality disorders. The countertransference potential to enjoy humiliating such analysands, as well as the defensive functions of fear to humiliation, are noted.

Fear↗

Therapeutic strategy and psychoanalytic technique.

The role of therapeutic strategy within psychoanalytic technique is described. An antistrategic bias inherent in certain aspects of the "classical" technique is explored in relation to the historical development of psychoanalysis. Clinical expertise, which includes the making of strategic or tactical choices, is relegated to the "unofficial," due in part to this negative bias impeding the study of technical differences in favor of general agreement about a theory of technique that may differ considerably from actual clinical work. A case is presented that illustrates strategic choices in the management of a severe character resistance in a supervised analysis. Some consequences of a negative bias against therapeutic strategy as it relates to psychoanalytic training is described.

Adult↗

Clinical dimensions of masochism.

In this paper, I propose a general classification of masochistic psychopathology and describe relations between this clinical domain and other types of psychopathology. My main objective is to provide an outline relevant for diagnostic, prognostic, and treatment considerations of masochistic pathology. This includes descriptions of and relations among a wide variety of masochistic phenomena from the depressive-masochistic personality to extreme forms of self-destructiveness. Ego organization, object relations, superego development, narcissistic organization, and polymorphous perverse infantile sexuality are considered as codeterminants of the levels and clinical features of masochistic pathology. Finally, the relations between masochistic pathology and negative therapeutic reactions are reexamined.

Depressive Disorder↗

Sadomasochism, sexual excitement, and perversion.

Sadomasochism, an ingredient of infantile sexuality, is an essential part of normal sexual functioning and love relations, and of the very nature of sexual excitement. Sadomasochistic elements are also present in all sexual perversions. Sadomasochism starts out as the potential for erotic masochism in both sexes, and represents a very early capacity to link aggression with the libidinal elements of sexual excitement. Sexual excitement may be considered a basic affect that overcomes primitive splitting of love and hatred. Erotic desire is a more mature form of sexual excitement. Psychoanalytic exploration makes it possible to uncover the unconscious components of sexual excitement: wishes for symbiotic fusion and for aggressive penetration and intermingling; bisexual identifications; the desire to transgress oedipal prohibitions and the secretiveness of the primal scene, and to violate the boundaries of a teasing and withholding object. The relation between these wishes and the development of erotic idealization processes in both sexes is explored in the context of a critical review of the pertinent psychoanalytic literature.

Adult↗

Sadomasochism in the neuroses conceived of as a pathological compromise formation.

Masochistic phenomena in adults are discussed as derivatives of conscious and/or unconscious fantasies. These masochistic fantasies are always associated with conscious and/or unconscious narcissistic and sadistic fantasies. These fantasies, like all fantasies in adults, are conceived of as compromise formations. After a selected review of the literature, analytic data are presented to highlight the clinical advantages of a contemporary elaboration of the structural hypothesis for the understanding of sadomasochistic and sadonarcissistic phenomena.

Adult↗

The dread to repeat: comments on the working-through process in psychoanalysis.

This paper focuses on the process of working through in psychoanalysis. Reemphasis of the centrality of the empathic listening perspective and discovery of the selfobject transferences made it necessary to reconceptualize various aspects of the analytic process from the perspective of psychoanalytic self psychology. With the help of a clinical vignette, the paper illustrates the manner in which archaic defense organizations and newly developing psychic structures find a compromise solution in a transference symptom. Such symptoms can serve as nodal points in the process of working through; they represent a transitional phase between the old automatic responses to narcissistic injury and an increased capacity to use signal anxiety. The psychopathology that became illuminated in this process can be described phenomenologically as a self-defeating personality disorder.

Adult↗