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Psychoanalysis has passed through several dialectic steps of development. At present, it appears invigorated by social needs such as accountability and by object-relations theory and self-psychology. As the most rigorous application of causality to the understanding of human behavior, it is likely to endure into new social eras and outlive the various diluted and trendy fads.
I have suggested that the plea for increased respect for the religious patient's perspectives demands a willingness on the psychotherapist's part to acknowledge the unique reality of the patient's relationships with religious objects, a reality which extends beyond the assumptions and predicates of standard interpersonal models of human behavior. At the same time, the psychotherapist can legitimately expect of the religious patient a willingness (notwithstanding the customary resistances) to expose his or her religious feelings and relationships to the type of analysis which attempts to clarify the nature and quality of the interpersonal or psychodynamic bases and implications of religious material. The psychotherapist can not arbitrate moral claims and decisions for the patient, nor rightfully present himself as possessing the single, "true" understanding of religious experience. Yet the therapist can invite the patient to examine the moral implications of his psychological experiences and the psychological impact and consequences of his religious experiences. What knowledge we as psychotherapists possess about human nature can be used to influence changes in the lives of our patients which they find useful and relevant for living in the world they have created for themselves. But we must, I think, humbly anticipate qualities of human nature and relationship whose ultimate meanings may defy every convention and paradigm.
This paper describes the complex psychotherapy of a young man involved with white witchcraft and a coven of white witches during crucial phases of therapeutically activated processes of separation-individuation. Psychoanalytic concepts are applied toward a theoretical and technical understanding of such a unique therapy and of white witchcraft in general.
A set of criteria for psychoanalytic work that can be used to define various forms of psychoanalytic therapy is proposed. Four patients who were involved in short-term individual psychotherapy with the same therapist, but who evidenced considerably different therapy process and outcome, are used to illustrate the criteria. Implications for practice and research are cited.
Criticism of psychoanalysis as a scientific discipline has increased recently. Even though psychoanalytic theory deserves ample criticism by the scientific community for its ambiguous definitions, deficient construct validity and precarious operationalization of its procedures, as long as there are clinical observables susceptible of recording, psychoanalysis remains in the realm of science. The scientific merit is reviewed of some psychoanalytic concepts such as repression, the unconscious, psychic structures, and intrapsychic conflict. The possibility of objectivity, prediction, and confirmation of hypotheses is discussed.
A peculiarly effective intervention by the author's psychoanalyst is explored and discussed in terms of its implicitly expressive properties. It is placed in the context of the classical concept of opacity and more flexible Sullivanian ideas, as expanded and clarified by Havens.
The clinical implications of the "case-manager" system are explored through a detailed case presentation. It is demonstrated that the introduction of a third person into the therapeutic relationship compromises the therapeutic alliance and the transference. Under such conditions psychotherapy is impossible.
Psychotherapeutic work entails many paradoxes. Emphasizing the patient's imagery and deemphasizing theory enhances understanding at the manifest level, the level of hidden themes, and the level of transference-countertransference patterns. A useful therapeutic model embraces dilemma, promotes toleration of puzzlement, and views the therapist as editor of the patient's developing novel.
Hermeneutics as a method of approach has been used differently by many different authors, and in this paper I have reviewed the history and evolving employment of the hermeneutic approach. For the purposes of psychotherapists, the point of hermeneutics is that, in contrast to the natural sciences, it focusses away from the classical notion of the neutral independent observer (or subject or psychotherapist) as detached from the object of his or her study, the patient. All understanding in the human sciences is viewed by hermeneutics as arising out of a fusion of horizons between the investigator and the humans being investigated. The "knowledge" which arises from such an investigation is not some sort of immutable truth or essence, but is context dependent and a function of the "prejudices" which the investigator brings to the investigation. Diagnoses and formulations in the practice of psychotherapy, if the hermeneutic approach is employed, cannot be viewed as disease entities and natural science "facts," but rather as temporary formations that change with changing times, historical eras, cultures, and prevailing prejudices and practices. The problem of a hermeneutic psychiatry would be to steer between the Scylla of naive realism ignoring the major participation of the psychotherapist on the one hand, and the Charybdis of relativism, nihilism, and hopeless skepticism on the other. Much work remains to be done in order to clarify the role and limitations of hermeneutics, and to incorporate it into the clinical practice of psychotherapy, and this work must be done against the prevailing ideology of scientific materialism that characterizes our historical era. A hermeneutic psychiatry offers us the best hope of not losing sight of the methodological horizons that delimit our clinical work, and of widening these horizons so as to provide further understanding of our patients.
This paper explores the psychological development of a child who is genetically a boy (Chromosome 46XY). However, because of multiple defects, a decision was made at birth to assign the child the gender status of a girl. Research has shown that the gender-feedback effect resulting from parent-and-infant interaction even at an early age leads to the development of sexual differences in behavior. Based on this conceptual framework, this paper investigates the complex interaction of the forces that shape sexual nature. It examines the process by which this 11-year-old girl is attempting to establish her gender identity. This paper also explores the conflicts resulting from the discordance between gender and identity, and the expression of this in developmentally regressive behavior and intellectual underachievement.
The study supports the notion that what may be concealed in the supervisory process may be revealed in the dreams of supervisees. Supervision as well as patient work mean an intense emotional experience for supervisees, especially for beginners in psychotherapy. This emotional experience was reflected in dreams. The supervisory situation reactivates the supervisees' earlier relationships and problems with authority people. This was also expressed in dreams. Stages in the supervisory process have earlier been described in terms of the learning experiences of the supervisees. The present study provides evidence that the supervisory process should not only be described in terms of different stages of learning, but also in terms of different emotional stages, where especially the beginning and end period mean a strong emotional investment.
This paper has introduced the distinction between the usual form of psychoanalytic effort at self-analysis and the communicatively founded approach, which has been termed self-processing. The paper also introduces a new teaching modality that involves the education of professional and nonprofessional individuals in how to engage in private self-processing. The ground rules or frame of the self-processing class have been described in detail. The classroom work includes a self-processing exercise developed primarily by an origination narrator or presenter with the aid of the other participants. The effort usually begins with a dream or other origination narrative, to which the narrator abundantly associates. The search is also made for signs of emotional disturbance--indicators--which include deviant frame impingements by class members. Finally, the stimuli or triggers that have evoked the unconscious processing and material conveyed in the exercise by the presenter are identified and clarified. The frame-related impingements by the instructor are among the most powerful triggers for the class's unconscious processing and responses. The exercise should culminate with a linking of triggers and associated images. In this light, psychotherapy and the self-processing class are compared in terms of their ground rules and role requirements, and especially in regard to the healing powers of each. Therapeutic holding is seen as the primary mode of cure in therapy, while the insightful linking of themes and triggers seems to play the main healing role in a self-processing class. The implications of these observations and ideas for the two healing modalities--therapy and class--and for our understanding of human emotional functioning and information processing are discussed.
In this paper we have described how examining the film House of Games can lead to an enriched understanding of the concept of countertransference for both neophyte and experienced psychotherapists. This absorbing film portrays countertransference phenomena from a number of crucial perspectives: predispositions to countertransference, direct and indirect indicators, countertransference in the "totalistic" sense as well as countertransference in the "classical" sense, parallel-process dynamics between therapy and supervision and the value of social and professional support in managing this inevitable burden. Cinema is another method, along with more traditional supervisory and didactic approaches, of assisting therapists to increase their cognitive and affective mastery of countertransference phenomena by encouraging them to analyze their emotional reactions to patients. This is no small task. In summary, we believe that the recognition, analysis and management of countertransference reactions is a necessary and life long professional task for any serious psychotherapist.
I have discussed a group of borderline patients who can be conceptualized as having defects in character structure. There is no smooth, hierarchically arranged continuum from lower id-oriented to higher ego, secondary-process organized psychic levels. They suffer from psychic discontinuity, characterized by psychic lacunae, empty spaces devoid of psychological content. These lacunae are often the locus of somatic disruptions, a psychosomatic focus, which are manifested as psychosomatic symptoms. Though the treatment of these patients can be stormy, and, in some instances impossible, providing a setting in which these patients can comfortably regress and eventually get in touch with split-off parts of the self can lead to a manageable therapeutic interaction. On occasion, this might be life-saving.
Discussions on the role of self-disclosure during times of personal crisis have been mostly confined to the theoretical. Little clinical material has been published. For the writer, this lack contributed further to the sense of loneliness following bereavement, and to uncertainty in terms of how to provide adequate information to patients while protecting herself at a time of great vulnerability. Using case vignettes, the impact of a therapist's bereavement on patients treated in an outpatient consultation-liaison service is explored. Four patients are described--one woman and two men with very serious physical conditions bringing their own frailty and death very near, and one woman with a psychophysiological condition as part of a borderline personality disorder. The impact of personal crisis is discussed, in an attempt to review how such a situation should be handled, and particularly whether and how patients should be informed.
Based on a clinical theory that guides an interpersonal approach to adolescent psychotherapy, the author advances the proposal that there is a developmental sequence of the capacity for relatedness from early to late adolescence: from a stage of Detachment in Relatedness through Disappointment in Relatedness to Mature Relatedness. In this paper, evidence from several broad-based studies of the social development of normal adolescents is presented in support of this proposal. These studies have attempted to track the developmental changes in intimacy, peer conformity, and qualities of friendship.
The changing climate of "health care reform" and increased third-party intrusion into psychotherapy are raising challenges over the ethics of traditional psychoanalytic practices such as billing for missed sessions. The practice of billing for missed sessions is an integral part of some analytic psychotherapies and forms the basis of the field of operation of many therapies. When used in this way, the billing practices are unique in medicine in that only these therapies use billing as a part of treatment. This practice is used for a variety of practical reasons but especially to emphasize to patients that the therapy occurs in their internal lives and addresses the symbols they use in organizing their world view. The symbolic use of a time commitment and the obligation to pay for that commitment are necessary so as not to present the patient with a contaminated field of operation. In this way the practice is similar to many other areas of medicine, such as surgeries that are viewed as global procedures whose billing allows for time that is not actually spent in contact with patients. This paper discusses the clinical rationale for the ability to bill for missed sessions and its ethics in terms of the newer language of utilization review. By laying down the principle of billing as a practice parameter for an open-ended bundled service that is billed globally the author translates the practice into more modern utilization-review terminology.
This paper provides an overview of object relations concepts, applying them specifically to combined psychoterapy-pharmacotherapy of anxiety disorders. Anxiety in this clinical theory is conceptualized as arising from threatened loss of the self- and object-relationship. At a rudimentary level, individuals can attempt to manage potential loss through splitting and projective identification. As benign and loving experiences accumulate and ego functions neurophysiologically develop, whole object relations provide alternate and more modulated ways of coping with anxiety. In anxiety disorders, these more mature coping styles break down. Treatment combining object relations approaches to psychotherapy with pharmacotherapy pay particular attention to the relationship aspects and meanings of medication and prescribing. These approaches use the concepts of empathy, containment, countertransference, splitting, projective identification, and transitional object formation to help patients come to terms with their anxiety and with the treatment relationship.