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PubMed2001

The class that would not read: utilizing Bion's affect theory in group.

While Bion's group theory continues to inspire contemporary group psychotherapists, his theory of human emotion is not as well known. Bion also introduced a system of alphabetical and mathematic symbols to offer a shorthand for his epistemology in order to make his ideas accessible, flexible, and practical for the working clinician. This article presents aspects of Bion's theory and metapsychological shorthand to conceptualize effectual dimensions of group process, thinking operations, and countertransference. The constructs considered include Klein's paranoid-schizoid and depressive positions; manic defenses; basic assumptions; "proto-mental" and "pre-monitory" emotions; instinctive drives L, H, and K (plus or minus); beta elements; and alpha functioning. With these ideas, the author was able to work through aspects of a group experience in which, as leader, he unknowingly found himself at an opposite affective pole from the members.

Affect↗
PubMed2004

Concurrent group and individual psychotherapy in a psychiatric day hospital for depressed elderly.

Concurrent psychotherapy is used in various settings for patients of different diagnoses and ages. The concurrent group and individual psychotherapy of older adults with depressive disorders in a psychiatric day hospital is described, emphasizing phases of treatment and transference and countertransference themes uniquely relevant to working with depressed elderly patients in a day hospital. Case examples are offered to illustrate these issues. The special technical considerations that need to be utilized when multiple therapists and settings are present are described. The model employs the use of an integrative, interactive group therapy, along with various other group treatments and antidepressant medication, with individual therapy serving a subordinate but organizing role.

Adaptation, Psychological↗
PubMed1978

Notes on loneliness.

Loneliness in this article is discussed in order to make it more discernable. Psychoanalytic literature has been surveyed relevant to loneliness and related issues. Noted is the importance of individualism in America, citing Thoreau as a model for individualism. Edgar Allan Poe's story "The Man of the Crowd" is discussed to illustrate desperate loneliness. The topic of loneliness connects to issues of empathy, loneliness in treatment, the countertransference response to loneliness, the study of self experience, and the problems created by the use of the term identity. The historical perspective indicates how we are time bound to the vocabulary, theories, ideas and myths of our era, to which, in our loneliness, we cling.

Attitude of Health Personnel↗
PubMed1988

Correspondences and thought-transference during psychoanalysis.

Correspondences, when the analyst has not verbalized his disturbed thoughts and they appear in the patient's spoken associations during analytic treatment, are not due to a single cause. Rather, they occur under a variety of circumstances: chance, coincidence, communication through sensory stimuli and perceptions, sometimes of extraordinary subtlety; or possibly thought-transference. Even if the latter possibility were doubted, the correspondence still may have usefulness as a finding of significance for the treatment process itself. It may alert the analyst to repressive forces directed toward the mix of his disturbing thoughts (reality derived), residues of old conflict areas that these have activated, even if transiently, and also to the current state of his countertransference. Utilizing the patient's associations will increase the analyst's awareness and facilitate the latter's quickly working through of these elements. This will favor progress of treatment. As for the question of thought-transference, preliminary findings suggest that the conditions under which it seems to occur involve the simultaneity of (1) the analyst's tendency to repress disturbing thoughts (including activated infantile residuals) because of guilt at being distracted and (2) qualitatively similar conflictual themes emerging from repression in the patient's unconscious. It raises the question as to whether extrasensory communication is between the unconscious of the two persons involved, occurring at a time when two opposite forces--repression in the analyst and modification of repression of qualitatively similar idea-complexes in the patient--are operative. The subject of correspondences and thought-transference in psychoanalytic treatment requires further study.

Adult↗
PubMed1989

Sigmund Freud and money.

I have tried to clarify Sigmund Freud's attitude toward money during the different time periods of his life. Most biographers have written that Freud was born into a poor family that later was elevated to the socioeconomic middle class in Vienna. This traditional viewpoint can be supported by various of Freud's letters and writings. A very different viewpoint has been proposed by the well-known American economist, Peter Drucker. As has been noted, his parents knew the Freud family in Vienna where Drucker actually met Freud. Drucker contends that Freud unconsciously misrepresented his parents' financial situation by creating the myth that they lived in poverty. Furthermore, Freud also developed another myth that it was because of the strong anti-Semitism in Vienna that he was so delayed in being appointed a professor of psychiatry. Drucker points out that the majority of the Viennese physicians were Jewish and that Freud's becoming a professor did not entail a delay and was not affected by any anti-Semitism in Vienna. Another area of conflict between Freud and the other Viennese physicians was Freud's refusal to treat any of his psychoanalytic patients without a fee. Freud believed that treating a patient in analysis for free created a transference-countertransference problem that might doom the treatment to failure. Freud's transference explanation for not taking on charity patients did not satisfy many of his Viennese physician colleagues. They believed that Freud was given an opportunity to accept their traditional standards and turned it down. In their eyes, Freud rejected them, they did not reject him. The same reasoning applied to the Viennese physicians' request for some scientific proof of the efficacy of psychoanalysis. Freud could only provide them with anecdotal or testimonial evidence to support psychoanalytic treatment. This placed psychoanalysis in the category of a belief system and not a scientific treatment. Drucker explains Freud's "obsession" with having lived in poverty as a manifestation of his "poorhouse neurosis." According to Drucker this syndrome was frequently found among Viennese during the last quarter of the 19th century. It was an irrational and deep-seated fear that an individual and his family were on the verge of being placed in the poorhouse because they lacked any funds. Freud does not specifically mention his having this irrational fear or obsession, but he made several statements quoted here indicating such a dread. At a recent psychoanalytic meeting I asked Freud scholar John Gedo of Chicago if he thought Freud experienced a "poorhouse neurosis."(ABSTRACT TRUNCATED AT 400 WORDS)

Austria↗
PubMed1993

Idealization and its discontents: a reconsideration of the functions and limits of a psychic phenomenon.

This study defines and illustrates the connections and differences between an idealizing and capacitating relationship. We first identified the patient's requirements for an idealized object, both to facilitate the reinforcement of a circumscribed but positive sense of herself, and to ward off dysphoric affect states in the domains of core- and intersubjective relatedness. These requirements were then distinguished from her need at a deeper level (the true self) to find a capacitating object to affirm, tolerate, and contain the full range of affects in her lived experience with others. These two sets of requirements have a different feel in the transference; and countertransference responses may be a valuable means of recognizing and distinguishing each as elements of different structures of self-organization.

Adult↗
PubMed1995

Nothingness, meaninglessnes, chaos, and the "black hole" revisited.

In the present article some clinical material involving complaints of nothingness, meaninglessness, chaos, and the "black hole" is presented and discussed. The purpose of the discussion is to illustrate that it is not possible to interpret this material solely as representing the reemergence of psychosis or early infantile catastrophic states. It is necessary to analyze this material, along with all other material, on at least five channels of therapeutic listening that I have described in previous work on the subject. These channels are the traditional Freudian, the Kleinian, self psychology, the phenomenological, and the interactional channels of listening. They are based on utterly incompatible premises. In this article I reviewed them briefly and then tried to illustrate how they may be applied to the same clinical material. One hopes that it has been demonstrated that the emergence of this characteristic nothingness, meaninglessness, chaos, void, and black hole material should not be automatically attributed to any one underlying intrapsychic situation, but can have many meanings in one patient as well as a variety of different meanings in different patients. Because this material is so dramatic when it emerges and is relatively common in the patients we see in our clinical work today, it is very important not to be misled by preconceived notions of what it means; one might even argue that the insistence on certain preconceived interpretations of given material represents an unfortunate form of countertransference.

Adult↗
PubMed1997

Interracial psychotherapy: a report of the treatment of an inner-city adolescent.

This report demonstrates the effectiveness of long-term psychodynamic psychotherapy between a patient and therapist of different races. The patient's experience as a member of a minority was recognized, as were the psychodynamic meanings that race possessed in reference to identification, transference, resistance, and countertransference.

Adolescent↗
PubMed2005

The dog's role in the analyst's consulting room.

Joe, a Labrador retriever, has accompanied an analyst in the consulting room since the dog was age three. Patients uniformly find him soothing and reassuring. In this capacity, he facilitates the therapeutic alliance and the holding environment. In addition, he often functions as a transitional object and transference displacement. Patients frequently use him as an introject for certain qualities they desire, such as security, strength, and confidence. Sometimes he promotes enactments between the patient and the analyst. At other times, he functions as a countertransference displacement for the analyst. On occasion, he is incorporated into the patient's defensive maneuvers and resistance. In each of these roles, he facilitates key elements of the therapeutic process, including exploration, understanding, interpretation, and working-through. Perhaps his most important role is that of a nonjudgmental, supportive, loyal cotherapist. Case illustrations highlight Joe's various functions in the analyst's consulting room.

Adult↗
PubMed2005

A psychodynamic approach to screening for the metabolic syndrome.

This article boldly challenges the dynamic psychiatrist to engage directly and vigorously into a matter that many would prefer to regard somewhat passively. That passivity is no longer acceptable. The metabolic syndrome has become a central medical concern because of the epidemic of obesity. It causes cardiovascular disease, diabetes, some cancers, sleep apnea, sexual dysfunction, and infertility. Obesity leads to depression, anxiety, and osteoarthritis. Some atypical antipsychotic medicines contribute to the metabolic syndrome, but the epidemic is widespread independent of atypicals. Practical steps by psychiatrists to monitor metabolic parameters are not as simple as they appear to be. Yet this is an area of clinical practice that cannot be ignored. Psychodynamic therapists need to awaken to the health of patients because the metabolic syndrome is more life-threatening than self-mutilation and many other self-destructive behaviors. The article discusses countertransference and transference issues stirred up when physicians begin to take responsibility for the total health of their patients. Freud oriented us to focus on both sides of the mind body relationship. Recent research on obesity, hypertension, diabetes, sleep, anxiety,depression, exercise and dyslipidemia is reviewed from the viewpoint of how it impinges on the office practice of a dynamic psychiatrist.

Humans↗
PubMed2006

How endangered is dynamic psychiatry in residency training?

The future of psychodynamic psychotherapy in residency training is in jeopardy. New priorities and forces currently aligned in academic psychiatry challenge the importance of psychodynamic psychotherapy and, by extension, its core concepts of the unconscious, defense and resistance, transference and countertransference, and the past repeating itself in the present. The exit of psychoanalysts from academic centers in the last quarter of the past century was propelled by forces including biological psychiatry, managed care, and competition from other mental health disciplines. ACGME psychotherapy competencies introduced in 2001 renewed the focus on psychotherapy training in residency and set a residency training standard for psychotherapy competency. A recent shift in academia prioritizing evidence-based medicine and a shortage of psychiatrist researchers may threaten those gains.

Biological Psychiatry↗
PubMed2006

The psychoanalyst at the medical bedside.

Consultation-liaison psychiatry is now a subspecialty recognized by the American Board of Psychiatry and Neurology. The presence of the psychiatrist as a member of the medical team is the result of contributions by psychoanalysts in the 1930s, 1940s and 1950s who studied the psyche acting on the soma. Psychoanalysis, from its theoretical inception, was holistic, and brought together biological, psychic, and social-ecological perspectives to unravel the mysteries of somatic illness. The early psychoanalysts were retracing a biopsychosocial model whose origins could be found in ancient Greece. A patient who is medically ill is more than an illness. Subjective experience, experiences before the onset of illness, losses, and the triad of helplessness, hopelessness, and giving up all became areas for psychoanalytic study. Some medically ill patients present degrees of complexity that puzzle physicians. These patients require a psychiatric consultation and treatment. The alliance with the psychiatrist unravels the problems complicating their cases and results in a collaborative treatment with the treating physician. The psychoanalyst training residents in psychiatry during their period in a consultation-liaison service is able to teach transference and countertransference issues that arise with patients and nonpsychiatric physicians. The creation of such an alliance can be a difficult task for the authoritarian resident who may be culturally conditioned to a rigid doctor-patient relationship. With the guidance of the psychoanalyst-teacher, residents change, and patients benefit.

Cooperative Behavior↗
PubMed2006

A view from Riggs--treatment resistance and patient authority: I. A psychodynamic perspective on treatment resistance.

Treatment resistance has emerged as a significant issue in our era emphasizing biological treatments for psychiatric disorders. This article suggests that, particularly when Axis II disorders are part of the clinical presentation, a subset of treatment refractory patients responds to a psychodynamic treatment approach that includes careful attention to the meaning of treatment resistance, and to the importance of relationships and of patient authority in recovery. The importance of engaging the negative transference and countertransference in treatment is also emphasized. A case example is offered to illustrate the article's thesis.

Adult↗
PubMed2001

Dante's Divine Comedy revisited: what can modern psychoanalysts learn from a medieval "psychoanalysis"?

I realize after having gone over this material that I have done a sort of deconstruction of Dante's Divine Comedy which putatively attempts to raise the human vision to transcendent heights and to focus love on the love of God, but which along the way indulges in the very human aspects of pity, compassion, music, poetry, and the other arts, as well as reason and puzzlement. In this sense the poem is also an exposition of the value of the higher human faculties, which contrasts at times rather vividly with the apparently harsh autocratic fates that are assigned to some characters--who do not seem quite deserving of what is inflicted upon them. Here we have a collision between absolute faith in the judgment of God and human reason and compassion which sometimes seems to be unable to justify these judgments. In spite of the fact that Dante is trying to adhere to orthodox theology throughout, it is clear that his poetic soul has great difficulty in avoiding the depiction of characters for whom he has a secret sympathy. The central point of this study of The Divine Comedy is to emphasize how Dante, almost in spite of himself, expressed empathy and understanding for a variety of unfortunates either in the Inferno or in the Purgatorio. Virgil even scolds him for his compassion, arguing that God's justice is always correct and if God is angry at someone and punishes him or her, Dante should also be angry and not compassionate. Dante tries, but he cannot quite manage to do it. Translated into modern terminology, we can learn from this report of a medieval "psychoanalysis" an important lesson in our clinical work. Rigid adherence to rules such as those Freud himself proclaimed (although he never followed them), for instance in his famous demand that one be always opaque to the patient, and/or rigid adherence to one or another psychoanalytic theory, must be understood as a form of countertransference, a character flaw in the analyst. Each case demands its own approach and its own form or forms or channels of understanding, just as Dante offers us in The Divine Comedy. It is because he offers such a perspective almost in spite of himself that his poem transcends the medieval mind and becomes relevant to all ages and cultures. As a rule of thumb, when one finds one's instinctual convictions about how to proceed in conflict with one's theories and set of rules, something is wrong. It is with the greatest trepidation that a well-analysed psychoanalyst should force him- or herself to ignore an instinctual or intuitive feeling of how to respond to a patient because it conflicts with some theoretical principles or official rules of procedure. Such a conflict is a call for further self-analysis, consultation with colleagues, and creative solutions.

Humans↗
PubMed2002

Psychoanalytic peregrinations I: Transference and transference neurosis revisited.

The various meanings of transference and transference neurosis are reviewed with special attention to the various roles transference plays in the psychoanalytic process. A study of the provenance of transference is offered with some remarks on the crucial emphasis on understanding and interpreting the transference in psychoanalytic treatment. The danger of using other types of interventions as being manifestations of countertransference is suggested.

Defense Mechanisms↗
PubMed2004

Gender in the consulting room.

Gender influences psychoanalysis and psychotherapy in a variety of ways. This article discusses these with reference to the woman therapist and analyst. Choice of therapist is influenced by realistic, transferential, and stereotyped ideas such as (1), wishes for a role model, (2) unconscious fantasies for a better mother, and (3) ideas that women are more nuturent. Family and work conflicts, pregnancy, and lifestyle issues are special issues for the woman professional. Transference and coutertransference manifestations concern variations in erotic and eroticized transference, maternal and paternal transference, and paternal erotic countertransference. Some limitations of cross gender treatment are indicated.

Career Choice↗
PubMed2004

Elements of dynamics II: psychodynamic prescribing.

Scientific pharmacotherapy, as it should be, is based upon the results of aggregates of patient responses to treatments of specific target conditions for drugs. Although enduring personality traits are increasingly included as targets for pharmacotherapy, in the real world of psychiatric practice transference issues and the patient's character or personality traits play a larger role in the selection, dosage, tolerability, and outcome of treatment than is generally recognized or admitted, other than to attribute undifferentiated placebo effects. Transference and countertransference issues from the marketplace are described, as well as operational parameters of character, character-based decision making, and specific suggestions for medicating according to character types. A new field of psychodynamic pharmacotherapy is encouraged along with attention to culturally informed prescribing.

Combined Modality Therapy↗
PubMed2002

Mutilation of self and object: the destructive world of the paranoid-schizoid patient and the struggle for containment and integration.

Using case material, I have described the three overlapping phases of treatment that occur with some borderline, narcissistic, or psychotic patients. These patients are dealing with paranoid-schizoid experiences of the self and the object. In this part-self, part-object world, many shifting, opposing, and contrary states of feeling and thought occur. Acting out is the first phase of analytic treatment. This is an externalization of persecutory anxiety, primitive guilt, and phantasies of annihilation. Projective identification, splitting, and denial are common and tend to make for difficult transference and countertransference problems. During the middle phase of treatment, pathological superego states and manifestations of death instinct color the analysis. The death instinct reacts defensively to the sadistic superego. Technically, the destructive internal conflicts created by these two elements must be clarified and interpreted in the transference. Flexible analytic management and containment are crucial supplements to ongoing interpretation. If these chaotic patients are able to stay in treatment for a period time, the acting out and the superego/death instinct phase gradually give way to phantasies of loss. This is still a paranoid-schinoid perspective of loss, making it persecutory experience. Although depressive anxieties do enter the picture, these still involve pathological anddestructive states of guilt and all-or-nothing threats of abandonment and attack. A case was presented in which the patient managed to continue into the third stage of analytic treatment, long enough to benefit frominternal, structure change. In this final stage, the patient "O" was able to acknowledge, work through, and integrate her prior feelings and phantasies of loss, persecution, and abandonment anxiety into more manageable and reality-based depressive functioning.

Adult↗