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PubMed1977

Voluntary and involuntary treatment of aggressive patients.

The author describes his experiences in treating violent patients in group therapy. Problems include the divergent goals of therapist, patient, and society; the environmental limitations on incarcerated patients; countertransference issues; and magical expectations on the part of patients. Therapeutic goals must be somewhat limited with patients who are forced into therapy. It may be dangerous to "open up" such patients, especially when they face lengthy prison terms. The author suggests that distancing tactics be avoided with violent patients, who need to encounter another person who has dealt successfully with hatred, fear, and limitations.

Aggression↗
PubMed1977

Borderline rage and the therapist's reponse.

Borderline patients often engender feelings ranging from apathy to rage in therapists. The author views the borderline patient's rage as defensive against fear of total negation resulting from projective identification with hostile part objects. The therapist's withdrawal or anger parallels the patient's projection of affect. Countertransference offers the potential for understanding a patient's terror, but therapists may become fixed in identifications that distort their understanding. Clarity often comes slowly as the therapist directs attention to his/her own affective state in order to understand the patient's vulnerability.

Affect↗
PubMed1978

The psychodynamics and developmental psychology of the borderline patient: a review of the literature.

The author reviews the psychodynamics and developmental psychology of the borderline patient as described in the literature on intensive therapy, early mother-child interaction, and family interaction. Focusing on the borderline patient's characteristic difficulties in intimate relationships, he describes the patient's use of splitting and projective identification as seen in the characteristic transference-countertransference interaction in intensive therapy. These primitive defensive mechanisms, which are also utilized by family members, appear to contribute to a failure of empathic responses both during the child's early development and in the family interactions during his adolescence. The author concludes that conceptual attempts to relate adult and child phenomena, although highly speculative, create new and useful perspectives for the treatment of the borderline patient.

Adolescent↗
PubMed1978

Cross-sex supervision for cross-sex therapy.

The female supervisor can help the male therapist in training to overcome problems in cross-sex therapy by presenting herself as a role model, providing relevant literature, and sharing her own experiences as a woman and as a professional. By enabling the male trainee to identify safely with a woman in a position of relative power, she can help him to deal with the intrinsic limitations of empathy and with other problems, such as "countertransference deafness," that may block his work with female patients.

Adult↗
PubMed1979

Common mistakes in psychotherapy.

To better monitor the psychotherapy training of psychiatric residents and to understand therapist factors involved in a negative outcome to psychotherapy, the authors surveyed 20 supervisors on the frequency of mistakes made by resident therapists. Among the mistakes most commonly made were wanting to be liked by patients, premature interpretations, overuse of intellectualization, inability to tolerate patients' aggression, and avoidance of fee setting. The authors conclude that the mitigation of the most common errors requires open discussion of countertransference issues.

Clinical Competence↗
PubMed1979

Implications of increased dosage of neuroleptic medications during psychotherapy.

Unrecognized emotional reactions on the part of the psychiatric trainee may result in the inappropriate use of medications. To illustrate the possibility that increases in medication dosages may be related to the psychiatric clinician's lack of control, the authors present three clinical examples and discuss the concept of countertransference. A model of supervision is described in which the supervisor, trainee, and patient meet to correct these therapeutic distortions and reduce the amount of medication required.

Adult↗
PubMed1984

Overview: the female physician and her marriage.

Previous research has addressed the marital problems of male but not female physicians. The author reviews the literature on women in medicine, reports findings on 16 female physicians with dysfunctional marriages whom he saw as patients, and describes several problem areas: delayed help seeking, self-blaming attitude toward subjective symptoms, ambiguity in self-image, "passivity" in marital communication, role strain, unmet needs in husbands, bilateral competitiveness, and problems with intimacy and sexuality. The author emphasizes a biopsychosocial approach to treatment and discusses transference-countertransference issues.

Adjustment Disorders↗
PubMed1984

Abuses of the borderline diagnosis: a clinical problem with teaching opportunities.

The authors identify six ways in which the borderline diagnosis is commonly abused to express countertransference hate, mask imprecise thinking, excuse treatment failures, justify the therapist's acting out, defend against sexual clinical material, and avoid pharmacologic and medical treatment interventions. The paper focuses on diagnostic abuses that trainees present to clinical supervisors and educators. It attempts to show educators how to discern these abuses and turn them into teaching opportunities. These abuses are seen not only in trainees; they also occur in the professional community as a whole. Clinicians should expect the same diagnostic rigor of themselves that they expect of their students.

Acting Out↗
PubMed1984

Forensic psychiatry and applied clinical ethics: theory and practice.

The authors briefly describe and then apply a new method--applied clinical ethics--for identifying and working with ethical problems. This method, starting from the clinical context, develops ethical constructs that may be tested in clinical practice and revised if required. The work was done in the context of a combined university-county forensic psychiatric service. The authors discuss three of the identified ethical issues: effects of deinstitutionalization, countertransference with forensic populations, and prediction of dangerousness. They discuss the basis for developing ethical norms from clinical experience and suggest ethical guidelines for medical practice.

Adolescent↗
PubMed1985

The psychodynamics of prescribing in behavior therapy.

The assignment of therapeutic tasks derived from learning theory to the patient by the therapist constitutes behavioral prescribing. After discussing some issues involved in comparing schools of psychotherapy and briefly examining some behavioral aspects of the psychotherapist-patient relationship, the author considers psychodynamic implications of a number of behavioral prescriptions, including homework, relaxation training, systematic desensitization, flooding, assertiveness training, sexual therapy, and self-control procedures. The author then examines possible meanings of behaviorally prescribed change itself, briefly discusses countertransference in behavior therapy, and advocates a multitheoretical perspective for psychotherapists.

Assertiveness↗
PubMed1986

The dying psychotherapist.

A previously unpublished paper by a dying psychotherapist describes the therapeutic use of the ensuing grief reactions of five patients to his terminal illness to help them deal with the effects of their previous losses, deprivations, and abandonments. Follow-up interviews with these patients and their subsequent psychotherapists shed light on the efficacy of such therapeutic efforts, the character of the communication of the terminal illness, the transference and countertransference reactions that interfered with the inevitable separation, and conclusions by previous authors regarding patients' reactions to the deaths of their therapists.

Abortion, Spontaneous↗
PubMed1987

Clinical implications of adult developmental theory.

Multidisciplinary studies of adulthood have revolutionized thinking about developmental processes during the second half of life. These ideas are just beginning to be integrated with clinical theory and practice. The elaboration of the interface between the rapidly expanding developmental theory of normal adulthood and clinical intervention with older patients is a psychiatric frontier. Illustrating with clinical examples, the authors offer a rationale for using new diagnostic tools, suggest a revision of the theory of transference to include sources beyond childhood, and describe unique transference paradigms in older patients as well as equally phase-specific countertransference responses in their therapists.

Adult↗
PubMed1988

Empathy: misconceptions and misuses in psychotherapy.

The frequent misconceptions and misuses of empathy that occur during psychotherapy are related to confusion about the definition of empathy, misunderstanding of the difference between the process of empathy and the therapist's response of being empathic, countertransference exploitation of empathy to act out the therapist's needs, the therapist's unawareness of the "layering" phenomenon, and overlooking the patient's level of self-other differentiation. These misuses result in the patient's feeling misunderstood and damaged, with a subsequent weakening of the therapeutic alliance and, at times, a breakdown in self-other differentiation. Once identified, misuses should be addressed and explored in psychotherapy to offset disruptions in treatment.

Acting Out↗
PubMed1989

Fifty years after Freud: Dora, the Rat Man, and the Wolf-Man.

Three of Freud's case histories are reviewed and reexamined from the perspective of modern psychodynamic thinking. The Dora case illuminates advances in our understanding of adolescent psychology and countertransference. The cases of the Rat Man and the Wolf-Man draw attention to our increased awareness since Freud of the importance of the therapeutic relationship and the recognition that a two-person psychology is at work in the psychotherapeutic situation. The heuristic value of such comprehensive case reports is emphasized.

Austria↗
PubMed1989

A critical review of object relations theory.

Over the past 20 years, object relations theory has broadly influenced general psychiatry. Along with its insights, the theory has brought its own conundrums. This paper provides an overview of the theory, indicating its contributions--such as a basis for individual psychotherapy of severe disorders and a more effective understanding of countertransference--and its shortcomings--such as lack of an explanation for the effects of physical and cognitive factors on object relatedness. Object relations theory fills a niche in the biopsychosocial model but is not a complete psychology for general psychiatry. Rather, it is an addition to drive theory and ego psychology within psychoanalysis.

Adult↗
PubMed1989

Borderline personality disorder, boundary violations, and patient-therapist sex: medicolegal pitfalls.

The author addresses the issue of sexual relations between therapist and patient and the related boundary violations that are involved in such relations. He points out that patients with borderline personality disorder are particularly likely to evoke boundary violations, including sexual acting out. These patients apparently constitute the majority of patients who falsely accuse therapists of sexual involvement. Therapists who are aware of patterns of errors in therapy and countertransference--through education, anticipation, and forewarning--can avert the serious outcomes that result from these errors.

Acting Out↗
PubMed1998

A date with death: management of time-based and contingent suicidal intent.

OBJECTIVE: The patient who voices suicidal intent in terms of the future or in terms of certain life contingencies presents special difficulties for the therapist. The authors outline the challenges posed by this problem for assessment, clinical management, and risk management. METHOD: The authors examined and analyzed case examples from both clinical and risk-management aspects. RESULTS: Problematic cases can be grouped into categories that offer insight as to management. The authors discuss this area and offer suggestions for appropriate clinical responses to this challenge. CONCLUSIONS: The authors recommend that therapists 1) treat the expressed "date with death" as a communication to be explored, 2) explore the problem of helplessness while monitoring their own countertransference responses, 3) assess the patient's competence to inform clinicians about suicidal state, and 4) readily use involuntary commitment.

Adult↗
PubMedDate not supplied

Naked patients in the general hospital: differential diagnosis and management strategies.

Physicians and patients are frequently concerned, and, at times, distressed, by nakedness during clinical encounters. When nakedness appears, clinicians should attempt to establish the reason for it and determine whether it is appropriate for the situation. Establishing the etiology of nudity can facilitate care by hospital staff and help to modulate their countertransference reactions and behavior. The authors present and discuss three cases involving nudity at times other than during the physical examination, within the context of differential diagnosis and treatment alternatives.

Adult↗