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Revolution and evolution. A brief intellectual history of American psychoanalysis during the past two decades.

The past twenty years have witnessed revolutionary changes in the theory and practice of psychoanalysis in the United States. The previously dominant clinical model of ego psychology with its emphasis on ubiquitous unconscious conflict between instinctual drives and the demands of reality and conscience, all mediated by the ego, is now but one of an array of differing theoretical views vying for attention. The alternative competing theoretical and clinical domains can be loosely categorized under the rubrics of object relations, self psychology, and the off-shoots of these which include the relational and intersubjective frames. These insurgent models of mental functioning and development, all of which grow out of object relations theory and thus overlap conceptually, have significant implications for psychoanalytic technique. It is the purpose of this article to review aspects of these models and the historic and revolutionary changes that their appearance have effected in the psychoanalytic landscape. A brief summary will also be made of the more evolutionary advances that have occurred in ego psychology during the past two decades. The extant literature on these issues is complex and voluminous, not to say vast. In advance, I apologize for the necessarily selective and even idiosyncratic nature of this paper. Inevitably, many original and important contributions to the evolving mosaic that makes up contemporary psychoanalysis are ignored or short-changed.

History, 20th Century↗

Hidden shame.

Shame dynamics, after decades of neglect, reappeared in psychoanalytic thinking with increasing prevalence in the last thirty years. Shame that is hidden is an aspect of complex clinical phenomenology that is particularly likely to be missed and hidden further by partial psychoanalytic explanations that drive shame more and more from view. Shame is often hidden theoretically by formulations limiting conflict to conflict between drives or impulses and something opposing them. By contrast, the incompatible idea model propounded by Freud in Studies on Hysteria emphasizes awareness incompatible with the dictates of conscience, and hence is broader in scope and closer to actual experience. Although shame and guilt arise developmentally earlier than does a true sense of morality, these emotions and their unconscious variants become entwined with the individual's sense of morality as development proceeds. The dynamics of shame and guilt are considerably more complex than their phenomenology as overt emotions. Shame emphasizes weakness, vulnerability, and the likelihood of rejection--so much so that its acknowledgment often generates more shame. Guilt, however, since it is action- and power-oriented, often obscures shame and so defends against it.

Awareness↗

Narcissism and superego development.

To elucidate the role of the superego in th maintenance of narcissistic equilibrium, we reviewed Freud's ideas about narcissism and the superego as well as the relevant theories of Kohut, Kernberg, and certain ego psychologists. These latter authors offer an alternative mode of understanding narcissism more consistent with Freud's structural theory, one in which signal affects and superego functioning play a central role in normal development and in the pathogenesis of narcissistic disturbances. Early steps in superego formation were then examined schematically to elucidate the interaction of environmental influences and emerging psychic structure. We suggested that the first step in a developmental line toward superego formation is based on the affective qualities experienced in the course of self-object differentiation. Subsequent steps examined were introject and ego-ideal formation; compliance with th object; compliance with the introject; identification with the introject and the ego ideal; and finally, with oedipal resolution, the integration of superego nuclei into a progressively structuralized autonomous superego system. This system achieves growing independence from the drives and from pressures from early introjects during the course of latency, and functions to maintain the demands of the conscience and the standards of the ego ideal; rewards or punishments result when these demands and standards are or are not met. The final stage briefly considered here was the revision, modification, and elaboration of moral codes and the ego ideal as part of the adolescent process. Narcissistic vulnerabilities at various stages were pointed out in an attempt to stress that a particular clinical picture in later phases of development or adulthood may derive from any of several development points of origin and from one or more etiological factors.

Aggression↗

Superego processes in a collective society: the Israeli kibbutz.

An attempt has been made to examine some aspects of cultural conformity and superego development in the Israeli Kibbutz. The basic premise has been that in a collective society, such as the kibbutz, with its multiple child-caretakers, we find a superego based on internalized values rather than introjected specific figures--a collective superego. The result is a shame- as opposed to a guilt-oriented conscience, with resulting emphasis on the need for the presence of others as controlling forces.

Child Development↗

Embryo research: the significance of the new law.

Embryo research is lawful in the United Kingdom: Human Fertilisation and Embryology Act 1990. Subject to licence and regulation. Embryo research raises medical, scientific, legal, social, philosophical, and ultimately conscience, moral and ethical issues. In the end each individual has to make his own value judgment, to be respected by all the rest of us.

Beginning of Human Life↗

Nurses' participation in the euthanasia programs of Nazi Germany.

During the Nazi era, so-called euthanasia programs were established for handicapped and mentally ill children and adults. Organized killings of an estimated 70,000 German citizens took place at killing centers and in psychiatric institutions. Nurses were active participants; they intentionally killed more than 10,000 people in these involuntary euthanasia programs. After the war was over, most of the nurses were never punished for these crimes against humanity--although some nurses were tried along with the physicians they assisted. One such trial was of 14 nurses and was held in Munich in 1965. Although some of these nurses reported that they struggled with a guilty conscience, others did not see anything wrong with their actions, and they believed that they were releasing these patients from their suffering.

Attitude of Health Personnel↗

Immoral behaviour in medicine.

The purpose of this paper is to emphasize a social phenomenon that exists in Israel: immoral medicine. In recent years, nurses have been exposed to many instances of immoral medicine in hospitals. We want to protest about the demands for money from patients who are waiting for surgical intervention, arouse the medical community's conscience concerning these immoral activities, and improve professional and moral behaviour.

Conflict of Interest↗

Beneficent voluntary active euthanasia: a challenge to professionals caring for terminally ill patients.

Euthanasia has once again become headline news in the UK, with the announcement by Dr Michael Irwin, a former medical director of the United Nations, that he has helped at least 50 people to die, including two between February and July 1997. He has been quoted as saying that his 'conscience is clear' and that the time has come to confront the issue of euthanasia. For the purposes of this article, the term 'beneficient voluntary active euthanasia' (BVAE) will be used: beneficient from the prima facie principle of beneficience, to do good, and voluntary to indicate that this must be carried out at the request of a competent client. This implies adherence to another prima facie principle, that of respect for autonomy. Active implies that something is done or given with the intention of hastening death. The word euthanasia itself simply means 'good death'. This article examines the moral positions of two nurses and one junior doctor towards the subject of BVAE and an attempt is made to represent the main conflicting moral positions. The central arguments against BVAE and counterarguments are presented. The conclusion reached is that consenting adults should not be prevented from availing themselves of BVAE if another consenting adult (a medical doctor) is available and capable of carrying out their wishes. This being the case, it is suggested that BVAE should be available as an option in hospices and in the community. The aims of this article are: to generate debate among professionals; to present a three-way discussion that might be useful as a focus for educational purposes, particularly at undergraduate level; to challenge professionals to confront the issue of euthanasia; and to plead the case of those who request assistance in exercising autonomy by gaining control over their own deaths.

Adult↗

Conscientious objection to assisted death: can pharmacy address this in a systematic fashion?

OBJECTIVE: To describe a legal structure for the accommodation of pharmacists' rights of conscience in the dispensing of drugs for pharmaceutically assisted death. BACKGROUND: Pharmacists have indicated that there is disagreement in the profession regarding the appropriateness of a practice known as "pharmaceutically assisted death," in which lethal medications are prescribed for terminally ill patients who want to end their lives. Pharmacists who object to pharmaceutically assisted death may be asserting a conscientious objection that threatens to create a conflict with their employers. In addition, pharmacists who support pharmaceutically assisted death, but whose employers forbid the dispensing of medications for this purpose, may face a similar conflict. Current laws and principles of professional ethics fail to adequately address the resolution of either of these conflicts. DISCUSSION: We propose a system within which the pharmacy profession could accommodate the right to conscientious objection without sacrificing the quality of patient care. At the heart of our proposal is the understanding that employers must respect an employee's right to beliefs that differ from those of the employer and, correspondingly, the understanding that employees must respect the employer's duty to provide products and services to those who seek them from the employer. CONCLUSIONS: Pharmacy associations can adopt policies for conscientious objection and have those policies become law through action of the state legislature or the state board of pharmacy. This approach could lead to the development of a clear policy and procedure for resolving the issue of conscientious objection within the pharmacy community, making it far less likely that institutions outside pharmacy would be required to develop a solution for pharmacy.

Ethics, Pharmacy↗

Community care: an analysis of assumptions.

The implementation of a policy of "community care' is seen to involve a number of assumptions, some of which are rarely examined. These can be roughly categorized as involving the nature of mental illness, the nature of community, the course and treatment of mental illness, the proper scope of psychiatry, the burden on the community and the efficacy of social work. Data bearing on these assumptions are reviewed, and the conclusion is offered that they are far from being uncontentious. It is suggested that the movement toward community care has many of the attributes of a moral enterprise which, unless substantiated by benefits to the patient or his family, may be the latest diversion of the psychiatric conscience from the care and treatment of the chronic mentally ill.

Aftercare↗

A projective analysis of guilt: the Holtzman Inkblot Technique.

The group version of the Holtzman Inkblot Technique (HIT) and the three subscales of the Mosher Guilt Scales (Sex Guilt, Hostility Guilt, and Morality-Conscience Guilt) were administered to 44 undergraduate college females in an effort to determine whether or not high-guilt subjects would demonstrate response inhibition on the HIT. The results indicated response inhibition on the part of high-guilt subjects relative to the HIT Human, Movement, and Integration variables. It was concluded that high-guilt subjects responded to the HIT in a style that was less creative and more perceptually immature than low-guilt subjects.

Journal Article↗

Role of ethics in modern healthcare: 1.

What is ethics and where does it leave the individual conscience-controlled practitioner? In this, the first of two articles on ethics in modern healthcare, the former question is examined.

Bioethical Issues↗

Role of ethics in modern health care: 2.

The first article in this two-part series examined the meaning of ethics, why nurses should bother with it, and what effect it has on the individual conscience-controlled practitioner. This article looks more closely at why nurses need to be aware of the implications of ethics in practice.

Decision Making↗

Society's search for a legal and ethical basis of physician-assisted suicide.

A review of the way physician-assisted suicide (PAS) is being addressed in the United States reveals three models, each functioning out of distinctive concepts of autonomy: (1) litigation, which utilizes philosophical autonomy; (2) legislation, which utilizes political autonomy; and (3) act of conscience by a physician, which utilizes consumer autonomy. Each model raises a correspondingly distinct set of ethical questions and challenges centered around their point of reference-the judicial system, voters, or the doctor-patient relationship. In the end, however, efforts to resolve the challenge of PAS will falter if they do not go beyond these models of autonomy. Religious institutions offer a more constructive setting for facing the life and death decisionmaking of PAS. The challenge for religion is to address PAS in solidarity with sufferers, physicians, and the community, rather than retreating into iconoclastic dogmas.

Aged↗

Working together: the National Association of Gay Alcoholism Professionals.

This article briefly describes the formation of the National Association of Gay Alcoholism Professionals (NAGAP). It then discusses the need for education, information, and advocacy that prompted the development of NAGAP's goals. There are four primary goals: (1) creating and fostering a network for support and communication among gay and lesbian alcoholism professionals; (2) educating those who work with gay/lesbian alcoholics; (3) raising the gay and lesbian communities' consciousness about alcoholism; and (4) improving treatment for gay/lesbian alcoholics, partly through advocacy. NAGAP's ultimate goal is to serve as a national "voice of conscience for the whole alcoholism field."

Alcoholism↗

Sodomy and kingcraft in Urania and Antony and Cleopatra.

Despite his description of sodomy as a horrible crime that a king is "bound in conscience neuer to forgiue," James I pursued the affections of a string of young and handsome "favourites" on whom he lavished gifts, titles, and power. Relying on the evidence of the King's own letters and frank comments from his Puritan critics, most historians assume that his relations with some of these men were sexual. The King's friendship with Robert Carr (who was later made Earl of Somerset), coupled with his estrangement from Queen Anne, may have been an inspiration for at least two literary accounts of kingship confounded by sex: Lady Mary Wroth's Urania (1621) and Shakespeare's Antony and Cleopatra (1608). Wroth describes a duke who is made politically vulnerable by his love for a young man that leaves him "issue-les." The rise and fall of this disloyal companion closely resembles that of Somerset and would seem to indicate Wroth's belief that the King's relationship with the Earl was sexual. Antony and Cleopatra is in many ways a reflection of Jacobean court extravagance and decadence. Cleopatra, despite her sex, seems to fill the same role in political and sexual scandal as did Somerset; and Antony's vacillation between pleasure and duty recalls a certain Renaissance discourse on sodomy and "kingcraft".

Drama↗

Postfertilization effect of hormonal emergency contraception.

OBJECTIVE: To assess the possibility of a postfertilization effect in regard to the most common types of hormonal emergency contraception (EC) used in the US and to explore the ethical impact of this possibility. DATA SOURCES AND STUDY SELECTION: A MEDLINE search (1966-November 2001) was done to identify all pertinent English-language journal articles. A review of reference sections of the major review articles was performed to identify additional articles. Search terms included emergency contraception, postcoital contraception, postfertilization effect, Yuzpe regimen, levonorgestrel, mechanism of action, Plan B. DATA SYNTHESIS: The 2 most common types of hormonal EC used in the US are the Yuzpe regimen (high-dose ethinyl estradiol with high-dose levonorgestrel) and Plan B (high-dose levonorgestrel alone). Although both methods sometimes stop ovulation, they may also act by reducing the probability of implantation, due to their adverse effect on the endometrium (a postfertilization effect). The available evidence for a postfertilization effect is moderately strong, whether hormonal EC is used in the preovulatory, ovulatory, or postovulatory phase of the menstrual cycle. CONCLUSIONS: Based on the present theoretical and empirical evidence, both the Yuzpe regimen and Plan B likely act at times by causing a postfertilization effect, regardless of when in the menstrual cycle they are used. These findings have potential implications in such areas as informed consent, emergency department protocols, and conscience clauses.

Contraceptive Agents, Female↗

Pharmacist critique was ill-informed.

Pharmacists' ability to exercise "professional right of conscience" in dispensing emergency contraception, as well as the professionalism of pharmacists, has fallen under attack recently by the media, by state governments, and even by other healthcare professionals in published commentaries. This editorial discusses the controversy surrounding emergency contraceptives, the right of pharmacists to refuse to fill prescriptions that they consider morally objectionable, and the responsibility of pharmacists to provide medications in a timely and professional manner. The professionalism of pharmacy is also examined in light of the expanded scope of practice in which pharmacists increasingly find themselves practicing.

Attitude of Health Personnel↗