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Psychoanalytic psychotherapy in Japan: the issue of dependency pattern and the resolution of psychopathology.

In this paper, I have tried to describe some of the characteristics of psychoanalytic psychotherapy in Japan in terms of dependency patterns in the psychotherapeutic relationship and the resolution of psychological problems. In the beginning of my paper I described problems concerning the professional network of psychiatry and psychotherapy in Japan and looked at the general attitude of the people toward this type of therapy. Then I briefly mentioned the attraction of traditional folk healing practices and outlined two of the academically acknowledged psychotherapies which originated in Japan. I have also presented characteristics of psychoanalytic psychotherapy practice in conjunction with those Japanese psychotherapies, discussing them in terms of the following issues: 1. General differences in psychoanalytic psychotherapy as contrasted to Naikan and Morita therapies and problems in psychoanalytic treatment that result from these differences. 2. Symptom resolution patterns in psychoanalytic treatment in Japanese patients and in relation to dream interpretation. 3. The cultural pattern of transference and how this relates to the Buddhistic figure of Kannon. 4. The Ajase Complex, a model of maternal transferential issues and an interpretation of objected-relations among the Japanese, namely the importance of forgiveness as a resolution of guilt and resentment. 5. The Amida Complex, a model of the cultural pattern of countertransference and the feeling of omnipotence and need for praise in the therapist. 6. Some complications and characteristics of a patient's perception of psychoanalytic interpretation. 7. The patient's perception of the psychoanalytic psychotherapist.

Attitude of Health Personnel↗

Termination in the Dora case.

Freud's insistence on interpreting Dora's second dream after she had announced that this would be her last analytic session illustrates his preoccupation with dreams as well as his failure to understand what Dora wanted from the analysis. Freud remained concerned with the relationship between Dora's symptoms (dreams) and her psychic reality; she was more interested in the external realities of her life, e.g., leaving analysis. Although the theme of termination was noted in Freud's interpretation of Dora's first dream, it was neglected during the final two weeks of the analysis. Freud's interpretations of Dora's dreams became the subject of the analysis, and Dora felt excluded. Several aspects of Freud's negative countertransference have been noted above: the analytic situation in many ways paralleled Dora's relationship with her mother; negative maternal elements in the transference destroyed any hopes Dora might have had of finding a suitable parent in Freud. The analysis ended with both Freud and Dora feeling betrayed.

Adolescent↗

Forced terminations.

Forced terminations are common clinical experiences and pose particular challenges and opportunities. They fall into four categories: mutually agreed upon, unilaterally forced by the patient, forced by realistic external circumstances, and unilaterally forced by the therapist. These differing situations are examined and compared, with attention directed to the use of reality as resistance, to the narcissistic injury in forced terminations, and to the potential transference-countertransference collusions to avoid powerful reactions to separation and loss. Problems with masochistic patients are considered opportunities for "bad endings." Technical considerations are discussed.

Choice Behavior↗

Medication consultation and split treatment during psychotherapy.

In split treatment a patient simultaneously sees both a psychotherapist and a pharmacotherapist. Research indicates that medication and psychotherapy have additive value when used together in the treatment of depression and probably in other disorders as well. However, little is known about the presumably common technique of separate therapists administering these treatments. Complex interpersonal issues arise, reflecting both ideological and transferential attitudes toward medication as well as the intricacies of triangular relationships. Establishing a three-way therapeutic alliance, awareness of competitive countertransference feelings, and recognition of covert issues other than medication in the request for consultation are examples of areas where special attention can help the treatment succeed.

Adult↗

Preserving a sense of wonder: the integration of an ego-supportive psychodynamic approach to supervision in an AIDS psychiatry fellowship.

The challenges of working with medically and mentally ill persons with a paucity of resources, inadequate networks of social support, and multiple stresses and losses maybe daunting to even the most seasoned of caregivers. A psychiatric trainee may be overwhelmed by the despair, sorrow, and desperation en-countered in the day-to-day care of the complex severely ill patient with lethalmedical and lethal psychiatric diagnoses. Individuals who are infected with HIV and hepatitis C, who are polysubstance users, and who are benzodiazepine dependent present with inordinate demands for prescribed substances to use or to sell in the street. The trainee needs to become comfortable with both limit-setting and harm reduction in order to keep the patient engaged in both lifesaving medical and psychiatric care. Nurturing and supportive supervision enables the trainee to integrate skills and work toward an understanding of countertransferences. An ego-supportive psychodynamic approach to supervision in an AIDS psychiatry fellowship facilitates conflict resolution and improves the care of patients with complex and severe medical illness.

Acquired Immunodeficiency Syndrome↗

The relevance of psychodynamic psychotherapy to understanding therapist-patient sexual abuse and treatment of survivors.

Regardless of the therapy modality, research continues to point to the therapeutic relationship as a major salient factor in clinical success or failure. When a patient is sexually abused by his or her therapist, this therapeutic relationship is cynically exploited in a way that does not properly serve the essential needs of the patient. When this patient then seeks reparative therapy, the subsequent therapist needs to pay close attention to issues of the relationship which were breached by the previous clinician. In this article, two case studies showing very different dynamics will be presented in order to demonstrate: (1) relevant factors related to transference, countertransference, projective identification, and the analytic third pertaining to the former, abusive therapy; and (2) needs versus wishes, and issues related to boundaries and self-disclosure in the corrective therapy.

Attitude↗

The secret life of the psychoanalyst.

In this article I have discussed what philosophers formally call subdoxastic about. Subdoxastic states are unconscious states about something that lead to conscious beliefs and conscious experiences. In the field of psychoanalysis Sullivan's (1953) "malevolent transformation" is a simple example of this. We all known how patients who have unconsciously undergone this kind of transformation of beliefs about people often appear more or less openly, depending on how well they are able to hide it, to be paranoid, suspicious, angry, and mistrustful of everybody, with the result that their conscious behavior and attitude alienate people and drive them away, resulting in experiences serving to verify the patients' beliefs. Psychoanalysts, we hope, are more subtle. Because they operate in a situation where there is little consensual validation and public scrutiny, the temptation to such syndromes as "compromise of integrity" or "partial private schemata" is very strong, leading to enactments that can be damaging to both patient and analyst and ultimately to burnout, as I have described it in this article. It is necessary, therefore, for analysts to keep a careful check on their conscious value systems and beliefs and to maintain continuing self-analysis for the subdoxastic factors that shape such beliefs. It is not possible to hide this from patients, and we must assume that sooner or later the patient gets to know the analyst pretty well. Analysts displaying the syndromes just mentioned, which are more subtle than ordinary character pathology such as that which forms the all-too-pervasive narcissistic analyst, may not even be aware they are doing so if they do not maintain a continual self-scrutiny, and if they do not pay close attention to their patients' material. This material--the patients' dreams, free associations, behavior, and enactments in the analytic process--often reflects not only transference but also constitutes a response to the analyst's unconscious and conscious value systems, which in turn are based on the subdoxastic factors that make the analyst the person that he or she is. Some patients may even precipitate crises or other situations that test the analyst's value system and force the analyst to display his or her secret self in immediate decisions that cannot be avoided. This is especially true if the patient is frightened or terribly threatened by factors in the secret self of the analyst; in this situation the patient may behave like a child who knows his or her father or mother is really very angry under a seemingly calm exterior, and as a result the child deliberately precipitates a display of that parental anger to get it out on the surface, get it over with, and reduce the child's anxiety. I have called for a genealogical study of analysts' choices of theoretical orientation in various cultures, and herein I am calling for a study of the subdoxastic factors in each individual analyst's theoretical orientation. Every theoretical orientation is based on a value system and a set of desires that determine the goals the analyst consciously or unconsciously wishes for the patient to actualize in the treatment process in order for the analyst to feel that he or she has catalyzed a "successful" treatment. This is a preliminary formulation. Further work is needed to distinguish between countertransference in the sense that we ordinarily use that concept today, and these subdoxastic factors determining the analyst's theoretical orientation and value systems, as well as to increase our focus on a subclass of these factors, the cultural ambience and background practices that Heidegger, for example, has identified as being crucial in the formation of the analyst's self as well as that of the patient.

Burnout, Professional↗

Therapists' relationships with their patients in the intake interview: an empirical comparison of psychodynamically and cognitive-behaviorally oriented psychotherapists.

This study was conducted in a real-life clinical practice setting and assessed the working alliances, countertransference feelings, diagnostic ratings, and prognostic judgments among psychotherapists at a university outpatient clinic. The study was based on the intake judgments of 9 psychodynamically and 4 cognitive-behaviorally oriented therapists, who had been assessed after having completed their diagnostic interviews with 144 and 89 patients, respectively. Cognitive-behaviorally oriented therapists perceived the quality of the working alliance to be better and their feelings of sympathy to be stronger than did psychodynamically oriented therapists. In addition, they perceived patients' motivation, the amount of shared understanding of the illness as well as several prognostical factors to be more favorable. The results may reflect different therapeutic philosophies and value systems inherent to the cognitive-behavioral and psychoanalytic orientations.

Adult↗

Not the same by any other name.

The names of individuals play a significant role in the organization of ego defenses and the consolidation of identity. Names have several conscious and unconscious meanings to patients in treatment. This article postulates that names also represent similar meanings to the therapist or analyst. The desire or reluctance to address a patient by a particular name can serve as an effective measure of the therapist's countertransference. This provides invaluable information about the patient's character structure and interpersonal relationships, which, if used appropriately, can favorably promote treatment.

Adult↗

Management of the borderline patient on a medical or surgical ward: the psychiatric consultant's role.

The patient with borderline personality hospitalized on a medical or surgical ward has a disorganizing effect on the house staff, who may regress in response to the patient's impulsivity, dependency, entitlement, and rage. The psychiatric consultant's role in the management of such a patient should consist of a specialized type of consultee-oriented approach in which countertransference hatred and fear, typically generated in the staff by the borderline, are drawn away from the patient and strategically metabolized within the staff-consultant relationship. The consultant should actively promote a behavioral management practicum, placed in the medical chart for reference and as a symbol of the psychiatrist's helping presence, which discusses: a) clear communication with the patient and among staff, b) understanding the patient's need for constant personnel, c) dealing with the patient's entitlement without confronting the patient's needed defenses, and d) setting firm limits on the patient's dependency, manipulativeness, rage, and self-destructive behaviors. The consultant should work to counteract feelings of helplessness in the staff, to neutralize punitive superego in the staff, and to diminish fearfulness toward the patient.

Adult↗

Executive functioning and compliance in HIV patients.

25 adult HIV patients were evaluated in a study of appointments, medication, and compliance with restrictions on sexual activity. The Executive Interview (EXIT) was useful in assessing these patients for cognitive difficulties; compliance with medication and countertransference issues were negatively correlated with EXIT scores.

Adult↗

The role of the therapist's critical parent.

The need for nurse therapists to be aware of their own feelings, beliefs, and attitudes is all-important if treatment is to be effective. In this paper, the author uses the concept of the therapist's Critical Parent (from Berne's 1961 Transactional Analysis model) to explore countertransference reactions. Clinical examples from the author's professional experience are employed to demonstrate the interplay of ego states between therapist and client and how understanding of the effect of the therapist's Critical parent can enhance his or her ability to intervene effectively.

Countertransference↗

The issue of race and the client-therapist assignment.

The client-therapist assignment can play an important part in the client's therapy. The impact of the variable of race within the psychotherapeutic process is an issue of ongoing controversy, and studies supply support for both same-race and differing-race dyads. With same-race assignments not always being accessible, it is the responsibility of the therapist treating the racially differing client to examine his or her own biases, motives, and countertransference problems that arise during the client's course of treatment.

Adolescent↗

Developing psychodynamic group treatment methods for aggressive male inpatients.

Group psychotherapy is one intervention that can be used for aggressive male inpatients. This paper reports relevant literature and clinical applications for conducting a psychodynamic psychotherapy group designed to help patients (a) identify, understand, and deal with underlying problems resulting in aggressive behavior; (b) improve interpersonal relationships; and (c) find more appropriate ways of expressing feelings, particularly those associated with aggressive behavior. The review of literature focuses on therapeutic approaches for dealing with aggressive feelings in group therapy; men's issues in group psychotherapy, including stages of group development for men and the expression of aggression; and the outcome of aggressive behavior in response to group therapy. Clinical applications discussed are preparation for the group; the group contract, including the "group as a whole" approach; patient selection; modeling authority; and countertransference and projective identification.

Adaptation, Psychological↗

Countertransferential and attitudinal considerations in the treatment of drug abuse and addiction.

This article explores countertransferential and attitudinal considerations in relation to their impact on the evaluation, diagnosis, and therapeutic management of drug-dependent individuals. Following a literature survey of the manner in which countertransference has been applied to the treatment of drug dependency, the authors discuss the status of the drug-dependent individual as a psychiatric patient and the resultant treatment implications when such a patient is viewed from within, rather than exclusive of, the mental health treatment delivery system. A number of examples are provided of patient-induced countertransferential reactions, in addition to specific attitudinal factors often present in the treatment of addiction.

Attitude of Health Personnel↗

Critical aspects of the psychodynamics of substance abuse and the evaluation of their application to a psychotherapeutic approach.

A model of psychotherapy is proposed which integrates psychodynamic theory, AA and other 12-step groups, family therapy, and dual-diagnosis issues into a phase-specific method. This therapy is done in three stages: (1) dryness (assessment and detoxification); (2) sobriety (achieving stable abstinence); and (3) wellness (using sobriety as a basis for personal growth and intimacy. The utility of an evolving concept of countertransference and new studies demonstrating the efficacy of psychotherapy are also discussed. Several challenging research questions are presented which, if answered, would assess the efficacy of this model.

Alcoholics Anonymous↗

The terminally ill patient on an acute psychiatric unit. A case study.

1. As mental health professionals, we frequently fail to realize that we are subject to the same emotions and coping mechanisms as the lay community. 2. At times it seems safer to focus on a patient's medical condition than to deal with difficult, unresolved psychological issues. 3. By using existing resources within our institution, our interdisciplinary team faced many of their unresolved issues about death, such as countertransference, and were able to then help our patient through his final stage of life.

Adult↗

Vicarious traumatization in the work with survivors of childhood trauma.

1. Persons working with victims of childhood trauma may experience traumatic countertransference and vicarious traumatization. After hearing a patient's trauma story, which is a necessary part of childhood trauma therapy, staff may experience post-traumatic stress disorder, imagery associated with the patient's story and the same disruptions in relationships as the patient. 2. During the first 6 months of working with survivors of childhood trauma, common behaviors of staff members were identified, including a lack of attention, poor work performance, medication errors, sick calls, treatment errors, irreverence, hypervigilance, and somatic complaints. 3. Staff working with victims of childhood trauma can obtain the necessary staff support through team support, in traumatic events, and in a leadership role.

Adaptation, Psychological↗