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PubMed2003

Psychic reality and the analytic relationship.

In this article I have argued that the more linear transformations or desymbolized expressions of one's earliest relationships are always a part of psychic reality and represent a unique opportunity in the analytic situation to transform a person's emotional orientation to the world. A necessary condition for this to come about is the analyst's capacity for sustained interest in the patient. This interest, which goes well beyond an intellectual one, can be threatened by countertransference as well as certain assumptions the analyst has about the nature of the analytic process. The analyst's belief in the analytic process, a belief that can only come from his or her own analysis, is seen as crucial in helping the transformational process that occurs in a successful analysis.

Fantasy↗
PubMed2002

Memory, neurodynamics, and human relationships.

In this article we discuss the implications of the functional organization and dynamics of the brain for understanding human relationships. In particular, we focus on the brain's multiple memory systems and the various roles they play in organizing the interactions of people as they come to know one another. The distinction between the relatively independent declarative, procedural, and emotional learning systems is especially significant in this regard, as the former mediates what we know about one another, the second mediates what we do with one another, and the third affects behavior by altering our emotional state. Knowledge of the functioning of these dissociable memory systems provides a novel perspective on relationships--both ordinary social relationships and those that develop in psychotherapy--and further illuminates psychotherapeutic transference and countertransference phenomena. We begin with a review of the neural basis of these processes, then turn our attention to the interpersonal level of analysis.

Brain↗
PubMed2004

Treatment considerations in the forensic patient with schizophrenia.

Research in new treatments for schizophrenia continues. At the same time, increasing numbers of persons with schizophrenia receive their treatment almost exclusively in correctional settings. Though the literature continues to describe this phenomenon in clearer detail, many questions regarding the characteristics of these mentally disordered offenders and their unique treatment needs remain. Research targeting this growing subset of persons with schizophrenia is limited. Risk factors that lead the person with schizophrenia into the correctional system, and whether the offenders with schizophrenia actually differ from non-offenders in terms of their psychopharmacological needs are significant questions that remain unaddressed. Countertransference towards the offender remains a significant issue as well. Given the many limitations on research in this population, pharmacologic strategies for the offender population must be extrapolated from the non-offender population. Traditional depot neuroleptics continue to be underutilized in the treatment of this population. It is argued that both traditional and forthcoming atypical depot neuroleptics may be the best first line agents in this population.

Antipsychotic Agents↗
PubMed1990

Staffs' interpretation of the experience behind vocally disruptive behavior in severely demented patients and their feelings about it. An explorative study.

This study illuminates the experience behind the vocally disruptive behavior in demented patients and their caregivers' reactions to it. Because of the communicative disturbances of the patients, caregivers were asked to act as their vicarious informants. Projective identification, transference, and countertransference were supposed to take place between the patients and their caregivers. Thus, a psychological framework was used. Seventeen experienced caregivers were interviewed after listening to tape-recordings of two patients exhibiting vocally disruptive behavior. Analysis revealed that caregivers regarded anxiety as the most common experience behind the behavior. Seven categories of explanations were obtained: anxiety over abandonment, dissolution, loss of autonomy, threats to integrity, an expression of bodily needs, reactions to disturbing environment, and automatic behavior. Caregivers wished to understand and help but felt powerless and insufficient. The results stress the importance of finding ways of interpreting severely demented patients exhibiting vocally disruptive behavior. The importance of supervision to support the caregiver in the extremely burdensome situation is also elucidated.

Anxiety↗
PubMed2004

An argument for a qualitative research approach to hypnotic experiencing and perceptually oriented hypnosis.

An argument for the significance of a qualitative research approach to hypnotic experiencing and a perceptually oriented view of hypnosis is presented with hypnosis framed in phenomenological, humanistic, and perceptual terms. An outline of threads of thought in Popper's writings are consistent with such a perspective. Qualitative approaches are noted and support for theoretical discussions leading to deeper understanding of issues of hypnotic experiencing, such as unconscious processes, nonlinear experiences, and researchers' countertransference are examined. Some limitations of current quantitative approaches to examining hypnotic experiencing and myths about qualitative research are discussed.

Humans↗
PubMed1976

Clinical guidelines for the cross-cultural treatment of chemical dependency.

Clinicians should be skilled in work with their ethnic peers before attempting cross-cultural treatment. Acquiring cross-cultural sensitivity involves regression to childlike openness for new values, attitudes, and behaviors. Members of the ethnic group can orient the clinician by discussion, suggested readings, and invitations to their homes and ritual events. Work should begin slowly, with regular consultation from ethnic peers of the patient. Special transference issues involve parent-child transactions and the "Messianic countertransference." Clinicians must maintain their primary commitment to the patient and to the patient's social resources, rather than to an institution not responsible to the patient population.

Asia↗
PubMed1990

A review of the borderline diagnosis for children.

The concept of the "borderline child" has gained increasing attention in the past 10 years. New diagnostic criteria are being proposed, and research is attempting to identify the salient features of the syndrome. This article examines the childhood borderline concept, reviews some new diagnostic systems, identifies the major diagnostic controversies, lists considerations for differential diagnosis, and discusses implications for practice. The intent is to present the state of the art of the diagnosis and to discuss some potential problems with its use. Unique aspects of the childhood syndrome in contrast to the adult disorder are highlighted. Overlap with other disorders, questions about the continuity of symptoms, lack of attention to developmental variables, and countertransference issues are a few of the problems identified.

Borderline Personality Disorder↗
PubMedDate not supplied

Transference interpretation in the psychotherapy of borderline patients: a high-risk, high-gain phenomenon.

The effectiveness of transference interpretation in the psychodynamic psychotherapy of patients with borderline personality disorder has been highly controversial. Both highly expressive approaches that stress the value of transference interpretation and supportive strategies that eschew transference work have been advocated in the literature. We review this literature and identify three emerging trends in thought: (1) Primarily interpretive approaches should be reserved for patients with greater levels of ego strength. (2) Whichever technique is used, a strong therapeutic alliance is the foundation of treatment. (3) Expressive and supportive techniques should not be juxtaposed as polarized opposites; supportive interventions often pave the way for transference interpretation. Our psychotherapy process study revealed that transference interpretations tended to have greater impact--both positive and negative--than other interventions made with patients with borderline personality disorder. We conclude that such factors as neuropsychologically based cognitive dysfunction, a history of early trauma, patterns of object relations involving interpersonal distance, masochistic tendencies, and anaclitic rather than introjective psychopathology are among the patient characteristics that influence the impact of transference interpretation on the therapeutic alliance. Bias toward expressive technique and countertransference issues appear to be relevant to the therapist's difficulty in shifting to a more supportive approach when indicated.

Adult↗
PubMedDate not supplied

The role of psychotherapy in the treatment of substance-use disorders.

Psychotherapies for substance-use disorders are reviewed, with particular attention to modifications of standard treatments necessary to make them effective for patients with disorders. Treatments reviewed include cognitive-behavioral therapies (Relapse Prevention, Cognitive Therapy, Contingency Contracting, Behavioral Treatment, Cue Exposure, Network Therapy, and Aversion Therapy) and psychodynamic/interpersonal methods (Supportive-Expressive Therapy, Interpersonal Therapy, Motivational Interviewing, and Modified Psychoanalytic Therapy). The psychotherapies selected are individual, verbally based treatments for substance-use disorders; except for modified psychoanalytic therapy, all have been presented in treatment manuals and empirically studied. Research shows that these forms of psychotherapy can be effective, with some treatments providing more benefit than others for specific subpopulations, but no one treatment is consistently more effective than any other. General guidelines consistent across psychotherapies for substance-use disorders are discussed, with emphasis on phases of treatment, the importance of a compassionate stance by the therapist, the difficulty of engaging substance abusers in treatment, the need for urine and breath-alcohol testing, assessment of comorbid disorders, countertransference problems, the need for multiple treatment modalities, evaluation of the therapist's effectiveness, adjusting the amount of treatment, and appropriate termination. Directions for future research are also discussed.

Humans↗
PubMedDate not supplied

Talisman or taboo: the controversy of the suicide-prevention contract.

The suicide-prevention contract is a widely used but overvalued clinical and risk-management technique. The scant information on this topic in the psychiatric and mental health literature is reviewed, along with the literature on collateral subjects including suicide prediction, medicolegal aspects of treating suicidal patients, the therapeutic alliance, and countertransference with suicidal patients. A group of 112 psychiatrists and psychologists was surveyed about their use of suicide-prevention contracts; the majority of them had never received any formal training on the topic. A combination of factors--the unpredictability of suicide, the many different antecedents to completed suicides, the complex psychological reactions of clinicians (including fear of litigation), the incongruity between clinical and legal usages of the contract concept, and the hazards that come of collapsing a complex treatment process into a few words--limit the applicability of suicide-prevention contracts. We reason that the use of these contracts is based upon subjective belief rather than on objective data or formal training. We recommend an alternative approach to suicide risk management rooted in the well-known and well-defined principles of informed consent.

Communication↗
PubMedDate not supplied

Enactment and the treatment of abuse survivors.

Regardless of the approach employed, treatment of patients with histories of sexual or other abuse is a formidable challenge. One reason for this is the vulnerability to "enactment" inherent in therapeutic work with such patients. Enactment is a recently elaborated psychoanalytic notion, defined as a pattern of nonverbal interactional behavior between the two parties in a therapeutic situation, with unconscious meaning for both. It involves mutual projective identification between therapist and patient. This paper clarifies the nature of enactment (conceptualized here as involving either refusal or actualization of the transference by the therapist) and its treatment implications. Transference-countertransference enactment paradigms encountered in work with survivors of abuse are presented. The therapeutic consequences of failing to recognize and respond to such enactments in work with these patients are explored. Unrecognized enactments may lead therapists unwittingly to abdicate the therapeutic role by becoming abusive, abused or vicariously traumatized, excessively guilty, seductive, overinvolved, and/or exhortatory or to implant false memories. Ways of utilizing enactment to advance treatment are also described and illustrated.

Adult↗
PubMed2005

Barriers to physician identification and reporting of child abuse.

Physicians systematically underidentify and underreport cases of child abuse. These medical errors may result in continued abuse, leading to potentially severe consequences. We have reviewed a number of studies that attempt to explain the reasons for these errors. The findings of these various studies suggest several priorities for improving the identification and reporting of child maltreatment: Improve continuing education about child maltreatment. Continuing education should focus not only on the identification of maltreatment but also on management and outcomes. This education should include an explanation of the role of CPS investigator and the physician's role in an investigation. The education should provide physicians with a better understanding of the overall outcome for children reported to CPS to help physicians gain perspective on the small number of maltreated children they may care for in their practice. This education should emphasize that the majority of maltreated children will benefit from CPS involvement. New York is the only state that mandates all physicians, as well as certain other professionals, take a 2-hour course called Identification and Reporting of Child Abuse and Maltreatment prior to licensing. Cited studies in this article suggest that such a mandate might be expected to improve identification and reporting, thereby encouraging other states to adopt similar regulations. Give physicians the opportunity to debrief with a trained professional after detecting and reporting child abuse. The concept of child abuse and the gravity of the decision to report can be troubling to the reporter. The debriefing could include discussions of uncomfortable feelings physicians may experience related to their own countertransference reactions. Provide resources to assist physicians in making the difficult determination of suspected maltreatment. The role of accessible telephone consultation should be evaluated, along with formalized collaborations with local Emergency Departments with pediatric expertise. Improve the relationship between CPS and medical providers. For example, CPS workers should systematically inform the reporting physician about the progress of their investigation and the outcome for the child and family. Several past reports have made specific suggestions to improve the working relationship. Warner and Hanson recommended that positive outcomes be programmed into the reporting process. They suggested that CPS have special phone lines staffed by well-trained employees for mandated reporters to call. Finkelhor and Zellman proposed a more radical change to improve the working relationship between CPS and mandated reporters. They suggested that certain professionals, with demonstrated expertise in the recognition and treatment of child abuse and registered as such, should have "flexible reporting options." Options include the ability to defer reporting, if there are no immediate threats to a child, or to make a report in confidence and defer the investigation until necessary. Finkelhor and Zellman emphasized that this model would improve physician-reporting compliance and enhance the role of CPS while reducing the work burden for CPS. Improve interaction with the legal system. Child abuse pediatric experts who have courtroom experience could provide education and support to physicians who have little preexisting experience with the legal system. Reimbursement for time spent supporting legal proceedings should be equitable and may reduce physician concerns about lost patient revenue. Retrospective studies and vignette analyses provide much information about some of the barriers to child maltreatment reporting and describe many of the reasons why physicians do not identify and report all child maltreatment. Future prospective examinations of physician decision-making may further explain the physician's decision-making process and the barriers he or she faces when identifying and reporting child abuse.

Child↗
PubMed1985

Breaking the race barrier.

Through the reflective process of analyzing one's own feelings and reactions to the ethnic minority patient, the white therapist develops an inner clarity that serves as a resource to cope with the unique conflicts one must confront in interracial practice. Only when the therapist has come to some resolution of his or her own feelings about the plight of ethnic minorities in this country can this acumen develop. Although the therapeutic skills applied in psychotherapy with ethnic minorities are in no way different from overall therapeutic skills, certain techniques may be especially useful in interracial practice. For instance, a discussion of the meaning of race and ethnicity in the relationship may curtail racial distortion, prevent stereotyping, and lead to the creation of a therapeutic alliance. When dealing with transference and countertransference issues, the therapist must be particularly attentive to the representation of these same distortions and stereotypes. Formulating clinical problems from dual perspectives, theoretical and sociocultural, is an arduous, but necessary task. Finally, the white therapist must be able to view ethnic minority patients as individuals. Although these patients cope with special problems which must be acknowledged and dealt with in therapy, the therapist must realize there is a common ground on which to communicate. On this common ground, therapists discover the foundation of interracial clinical practice is the ability to accept and respect their patients and themselves as individuals who may have similar anxieties, problems, experiences, and goals. It is through the recognition and sharing of the fundamental human bond that ethnic and racial differences, which may have detrimental effects on interpersonal relationships, are transcended.

Adolescent↗
PubMed1991

Integrating three approaches to counter resistance in a noncompliant elderly client.

1. The term "resistance' has been defined primarily in the psychoanalytic literature and is a significant issue in the treatment of mentally ill people. This issue needs to be addressed for the change process to begin. 2. An understanding of resistance from psychoanalytic, cognitive, and behavioral perspectives will enable the nurse to assist the client in achieving mental health. 3. Countertransferance can be used to understand the client's motives, hence becoming aware of therapeutic goals, or it can hinder the therapeutic process. 4. The psychiatric-geriatric population is complex. With the acceptance that an elderly client can benefit from psychotherapy and with an understanding of different approaches, the client may experience symptom relief.

Aged↗
PubMed1991

PTSD and the Vietnam veteran: the battle for treatment.

1. Patients with post-traumatic stress disorder (PTSD) often encounter treatment that is complicated by professional bias, personal issues, countertransference, and pathological staff dynamics. 2. Treatment is further complicated by diagnostic confusion, the dual diagnoses of substance abuse or depression, and symptoms that mimic personality disorders or psychosis. 3. The special circumstances of the Vietnam conflict that contributed to the susceptibility and etiology of PTSD are the individual characteristics of those who served, the special nature of the war itself and the military strategies used, and the psychosocial and cultural milieu in which it occurred.

Attitude of Health Personnel↗
PubMed1994

Patient violence toward a nurse: predictable and preventable?

1. It is estimated that half of all health care professionals will be assaulted at some point in their careers. 2. Prediction of violence depends not only on obvious factors, such as threats made by the patient, but also on more subtle violations of boundaries, such as patient contact with the clinician outside the clinical setting by telephone or in-person encounters in the clinician's home. A specific factor associated with danger seems to be the patient's perception of an unrealistic, "special" relationship with the person targeted. 3. Health care professionals should avoid creating a sense of guilt and shame in clinicians about such issues as countertransference. Staff members should be able to discuss issues without laying blame and possibly prevent dangerous situations.

Adult↗
PubMed1995

Serving time: psychiatric mental health nursing in corrections.

1. The opposing philosophies of custody and caring result in direct implications for nurses working in the correctional environment. Nurses constantly "walk in line" between the requirement of security, health care, and client advocacy. 2. Deinstitutionalization, increased rates of incarceration for interpersonal violence, and substance abuse related crimes have resulted in a rapidly expanding prison population. Of all offenders, 10% to 15% have a major mental illness, leading to many treatment challenges for the nurse. 3. Therapy issues with this population are complicated. Correctional nurses must have a good understanding of the therapeutic nurse-client relationship, with particular attention to therapeutic impasses, transference, and countertransference. 4. Historically, role development for nurses working in corrections has been particularly difficult. Correctional nurses must grapple with issues surrounding professional identity, professional isolation, and territoriality.

Criminal Law↗
PubMed2006

Boundaries & adolescents in residental teatment settings: what clinicians need to know.

Working with adolescents in psychiatric treatment settings poses unique challenges related to boundaries. Staff are typically from a range of disciplines, and some are from nonregulated professions. Three potential boundary-crossing areas are touching, gift giving, and self-disclosure. To enhance quality of care, staff needs an orientation aimed at boundary education, including the concepts of transference and countertransference; an atmosphere of safety to discuss their observations of themselves and others; to be willing to provide feedback; and a sound knowledge base of adolescent growth and development.

Adolescent↗