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PubMed1989

[Ethics in psychotherapy].

After introducing the terms "morality" and "ethics" as defined by Patzig, the discussion focuses on applying to the practicing of psychotherapy the guidelines for ethics in medicine formulated by Beauchamp and Childress, i.e. respect of the autonomy of the patient, the doctor's duty to prevent injury, the obligation to give assistance and the principle of fairness. In particular, it is pointed out that to hale respect for the autonomy of the patient, a thorough and patient inquiry concerning diagnosis, indication and therapy is necessary in order for the patient to develop intrinsic motivation based on insight into his condition and evaluation of the prognosis. In connection with the discussion of the nil nocere, reference is made to the therapist's duty to take a patient's various limits of tolerance into account. Emphasis is also placed on the psychotherapist's duty to "service" his own psychic apparatus with the help of continued education and in-service training, supervision and self-analysis. Applied to psychotherapy, the obligation to give assistance means encouraging the patient to go in the direction of greater autonomy which means the reduction of helplessness. In psychotherapy, problems of distributing resources fairly may be manifested in unjustifiably long waiting lists or in the form of patient selection carried out in a way that is not justifiable on medical grounds but based rather on a tendency to eliminate certain groups of disorders by using contra-indications that are basically rationalizations of countertransference reactions and which are not in keeping with the professional and personal identity of therapists.

Ethics, Medical↗
PubMed1989

Treating the patient who has been sexually exploited by a previous therapist.

Patients who have experienced sexual exploitation by a previous therapist constitute an increasingly recognized clinical population. Although some of these patients were transiently overwhelmed or mildly disturbed when exploited, the majority were severely symptomatic and the victims of incest or other previous abuse. Many demonstrate a constellation of four factors that predisposes them to revictimization or the sitting duck syndrome: severe symptoms, idiosyncratic dynamics, atypical socialization that discourages self-care, and cognitive difficulties. The experience of such exploitation is not benign, although the sequelae vary considerably. The treatment of such patients is facilitated by arranging the therapy in a way that maximizes safety and clear communication. The importance of hearing the patient' own reconstructions, pacing the treatment to the patient's tolerance, and respecting the patient's agenda cannot be overemphasized. A cluster of issues that appear central to the treatment of such patients includes addressing their helplessness, their ambivalence about the exploitive therapist, their difficulties with trust, their guilt, their depression and pressures toward self-harm, their confusion over sexuality, their post-traumatic and dissociative features, their severe symptoms and the diagnostic confusion this involves, and the countertransference pressures upon the therapist.

Ethics, Medical↗
PubMed1989

Anxiety in adolescence and its significance for psychoanalysis.

The theme of this paper is the well-known resistance of adolescents to participate in analytic treatment and analysts' reservations about treating adolescents, which is perhaps less well known. Several reasons are discussed: For adolescents, the revival of separational and fusional anxieties during the process of individuation as well as resistance to the analytic setting are held responsible; analysts may lack sufficient awareness of their own adolescence and its resulting anxieties to be able to confront this developmental period. In addition, there are countertransference anxieties that are triggered and kept alive by the behavior of the juvenile patient. The different types of analyst anxieties as well as those of the adolescent under analysis are explained and their significance in the process of individuation and the course of therapy is noted.

Adolescent↗
PubMed1989

The patient in the psychoanalyst's consulting room--the first consultation as a psychoanalytic encounter.

The first consultation with the psychoanalyst is described as a psychoanalytic encounter if the analyst conducts it from beginning to end in a psychoanalytic posture in which the work of interpretation is based on the unconscious scene of the transference-countertransference relationship. It then offers patient and analyst alike sufficient anticipatory experience to predict within limits what might be expected for both parties in a possible ensuing psychoanalysis. This conception of the psychoanalytic consultation is illustrated by a detailed case history.

Defense Mechanisms↗
PubMed1988

Victims of violence and post-traumatic stress disorder.

PTSD can occur in victims of violence. It is not known whether PTSD is caused by the psychological reaction of helplessness, shame, and guilt in the face of a traumatic stressor, whether there is some sort of fundamental psychobiologic change in the CNS in response to a stressor, or whether psychological reactions lead to biologic changes and both then coexist. PTSD after experiencing violence is characterized by re-experiencing phenomena, numbing or the avoidance of stimuli associated with the violent event, and symptoms of increased arousal. The disorder may begin immediately after the trauma or onset may be delayed for months or even years. Even after PTSD is resolved, it can return years later in response to an event that reminds the trauma victim of his earlier experience. Treatment consists of individual psychotherapy, family therapy, group therapy, and a range of pharmacotherapeutic interventions. Experimental therapies are being developed such as those that combine narcosynthesis and talking therapy, and descriptions of these appear in the literature. It is important for the psychiatrist attempting individual psychotherapy of a sufferer of PTSD for the first time to consider supervision with a colleague who possesses expertise in treating the disorder, for many treatment efforts fail because of countertransference reactions. Similarly, those who employ other forms of talking therapy will benefit from supervision.

Adult↗
PubMed1988

Management of the violent patient in an emergency situation.

The management of an acute episode of violence by a psychiatric patient is probably one of the most demanding actions in psychiatry in terms of clinical competence and emotional impact on the clinician. In such situations, consideration of the safety of staff and other patients is paramount. Interventions available to the clinician in the management of acute violence include verbal intervention, restraint, seclusion and medication. This article offers guidelines for how to communicate with the patient. Issues of countertransference and emotional reactions to patients are addressed. The author has worked to develop national guidelines for the psychiatric use of seclusion and restraint in terms of indications, contraindications, implementation, review by the physician and the monitoring and care of the patient by staff.

Emergencies↗
PubMed1987

Treatment of substance abuse in patients with HIV infection.

The dual diagnosis of AIDS and substance abuse raises serious clinical and ethical issues for health care providers. Often, there are barriers to the diagnosis and referral for substance abuse treatment in people with HIV infection. Countertransference is one such barrier. Important educational needs of patients can be overlooked or not fully addressed. Essential information needs to be conveyed, regardless of whether or not a patient seeks substance abuse treatment. Early intervention and treatment are essential to minimize risk for HIV infection and transmission to others. Specific clinical issues that practitioners often address for patients with AIDS or ARC are appropriate interventions for denial of the HIV-related diagnosis coupled with the denial of substance abuse, difficulties in pain management, the difficulties of family and loved ones, the need for substance abuse relapse prevention, and the need for coordination of care among agencies.

Acquired Immunodeficiency Syndrome↗
PubMed1986

Right on the money: disability forms and the hospitalized borderline patient.

Handling of the hospitalized borderline patient's request for disability compensation reflects the therapists's success or failure in keeping a sustained focus on splitting. This focus is crucial to the subacute hospital treatment of borderline psychopathology. Overprotectiveness or withholding of appropriate support results from countertransference reactions. Splitting is reinforced rather than minimized if the therapist fails to focus both on the damaged and overwhelmed aspect of the personality (how the patient feels) and on the irresponsible and manipulative aspect (what the patient does). The therapist who fails to respond to the disparate aspects in an integrated way risks acting out key aspects of the clinical picture to the detriment of successful subacute hospital treatment. The therapist's awareness of typical patterns of splitting can be enhanced by considering the patient's developmental history; current familial and vocational relations (or lack of them); and the patient's relation to the hospital staff.

Adult↗
PubMed1987

Difficulties encountered in the treatment of outpatient adolescents.

This paper discusses the paradoxes which become evident in the course of outpatient treatment of some adolescents. The resistance to treatment, the nature of therapeutic communication, the handling of countertransference feelings, and the view of the adolescent as victim are described. In addition the use of isolation by adolescents and its effect on therapy is discussed.

Adolescent↗
PubMed1986

Relationship security: the dynamics of keepers and kept.

Hiring, training and supervising treatment staff who work closely with forensic patients at all levels of security requires careful planning. In particular, staff must identify and share feelings like fear and anger that are always generated when patients threaten or attack staff. Approaches to dealing with staff countertransference to patients are suggested in this article, and aids to breaking the aggression cycle are discussed. Relationship security is a working through of dynamics that are always in operation where there are keepers and kept.

Adult↗
PubMed1986

Vicissitudes of identification as observed in character pathology.

This paper deals with identification and its vicissitudes as observed in character pathology. A clinical case of character neurosis is presented to demonstrate that it is possible, through transference analysis and especially through countertransference, to observe in character traits the vicissitudes of identification with an object. In this context it was possible to observe how painful affects, pathological narcissism, excessive use of defence mechanisms such as splitting, denial, repression, projective identification, all activated by primitive object relations determine specific unconscious fantasies. They also distort and cause difficulties in identification. It is also pointed out that failures in the external object strengthen the defensive processes which determines the formation of the character trait enclosing the history of primitive object relations.

Adult↗
PubMed1986

The management of sexual issues in adolescent treatment programs.

Disturbed adolescents confined to inpatient treatment settings present special problems for the management of sexual behaviors. Ego impaired, delinquent, and autonomy-seeking adolescents provoke unique conflicts among their peers and staff. Staff's sexual anxiety caused by societal stereotypes of adolescents, inexperience with the techniques of unbiased observation and limit-setting, ignorance of normal adolescent development, and countertransference may lead to inadequate or inappropriate interventions. The authors describe the goals of a training program to reduce staff sexual anxiety: to develop a body of knowledge about the interaction between normal sexual development and psychopathology; to promote awareness about the staff's own feelings and the ways they influence observation and interaction; to lessen anxiety about self-exposure in the group setting; and to gain mutual support. Specific guidelines regarding effective staff interventions at an individual and group level are described. Alertness to the broad implications of sexuality in staff and patients and the necessity for careful monitoring of ward anxiety is emphasized.

Abortion, Induced↗
PubMed1986

Civil commitment to outpatient psychotherapy: a case study.

Commitment to outpatient psychiatric treatment evolved in the courts to protect patients' right to freedom from compulsory hospitalization. This ruling has been criticized by the psychiatric profession, who prioritize treatment rather than liberty. The following case demonstrates the use of commitment as a therapeutic tool in the psychotherapy of a woman with severe borderline pathology. Although the use of coercion in psychotherapy is controversial, its potential use and its ramifications on transference and countertransference issues are discussed.

Adult↗
PubMed1979

[Multiple therapy (complementary therapy)].

The term "Multiple therapy" is used to describe the combined use of more than one therapist for one patient following a preconceived plan (German: "Komplementärtherapie"). Combined with dynamic ward groups this approach intensifies the impact of short term in-hospital treatment. The purpose of this strategy is to fragment the patient's defenses, to shorten the therapeutic process and to prime and prepare the patient for ambulatory treatment after discharge. The employment of Multiple therapy in a hospital minimally necessitates workable interpersonal relationships between the members of the team, intensive supervision to prevent countertransference problems and a compatible point of view regarding the goal of treatment amongst the staff. All therapeutic methods, new or old, are in the final analysis nothing else than what the word connotes: a method, a means to an end. They never represent the way itself. The quality of psychiatric therapy and treatment does not depend upon the method, be it multiple therapy, individual analytic therapy, one of the non-verbal methods used or any other. What really counts is 1) whether the method is used by a team which truly wants to cooperate for the benefit of the patient, transcending their own ego demands, 2) whether it really improves interpersonal communication. Every psychiatric patient is somehow alienated and removed from his fellow men. Therapeutic methods employed at the hospital are valid if they facilitate to bridge this gap. If that is achieved, therapy can be considered successful. If not, such approaches merely represent meaningless occurrences which at best foster an illusion that "something really happened". That is not the same as when we see the beginning of a healing process. The therapeutic atmosphere in the hospital is meant to create a climate wherein a natural innate healingpower of man will be liberated. The Romans knew it already: Medicus curat, natura sanat.

Adolescent↗
PubMed1984

[Fluctuations in the "evenly hovering attention" and their therapeutic processing].

For epistemological and empirical reasons, Freud's "evenly hovering attention" has to be understood as an advice that the analyst should remain open for new observation. It is a recommendation against having preconceived ideas and biases. In fact, the analyst's attention is regulated by conscious and unconscious selections. It is subject to considerable changes in the analyst's cognitive processes. His countertransference influences his attention. The patient in turn reacts consciously or unconsciously to the variations of the analyst's attention. It is therefore necessary to interpret those changes and sometimes to admit them. This recognition supports the reality testing of the patient in the analytic situation. Otherwise malign regressions or denials and other defensive processes might occur. We give an example of the changes in the "evenly hovering attention" of an analyst and their handling.

Adaptation, Psychological↗
PubMed1983

[Psychotherapy of schizophrenia].

Schizophrenic existence is the experience of an awful negativism, which comes from the depth of the Unconscious and appears at the surface of the conscience as the destruction of all positive symbols of life. Interpretations of psychodynamic mechanisms, of transference and countertransference, of dreams and fantasies must be rooted in the dominant therapeutic endeavour of creating with the remaining potentialities of the patient new positive symbols of the schizophrenic existence. The author's experience in the 30 years of his dealing with schizophrenic patients is here summarized.

Fantasy↗
PubMed1983

The general hospital psychiatrist as "compleat" therapist.

Four case histories have been presented to illustrate the range of therapeutic modalities which the liaison and consultation psychiatrist may be called upon to employ in the routine treatment of patients in the general hospital. These include analytically oriented insight and supportive psychotherapy, intervention with the family, collaboration with the medical and nursing staff, resolution of staff countertransference difficulties, pharmacotherapy, the turning of hospital and community resources to therapeutic account, and follow-up treatment and referral. Other more specialized modalities such as hypnosis (Frankel, 1978), amytal interview (Naples and Hackett, 1978) electroconvulsive therapy (Glaser, 1953), biofeedback and behavior therapy (Fordyce, 1978), and group therapy (Rahe, O'Neil, Hagan, and Ransom, 1975) have also proven useful. The synthesis of these skills into an individualized, coherent treatment approach is the challenge posed to the consultant by the 20 to 60 percent (Lipowski, 1967) of patients admitted to the general hospital with treatable emotional disorders. Because the vast majority of these disorders relate directly to the illness for which the patient was admitted and to the treatment rendered (Torem, Saravay, and Steinberg, 1979) they comprise a unique spectrum of psychiatric illnesses which often demand timely intervention (Solomon, Saravay, and Steinberg, 1980) before complete information is available. To effectively meet these challenges, the general hospital psychiatrist strives toward the ideal of the "compleat" therapist--creatively synthesizing an individualized approach from a varied therapeutic repertoire for each of the patients he is called upon to treat.

Adult↗
PubMed1984

Marital therapy for the elderly.

Little attention has been paid to marital therapy for the elderly in spite of its relevance to morale and emotional problems. Physical illness is of particular significance in altering the dynamics of the marital relationship. Retirement and financial problems, as well as changes in sexual activity and gender roles, are also important. However, radical changes in patterns of behaviour cannot be expected. Therapeutic techniques must be altered for this age group, and the therapist must be active, giving and concretely helpful. As with therapy for younger couples, children may need to be involved in the therapy sessions. Family physicians should be a main source of help for marital problems among the elderly. However, because problems related to countertransference must be faced, working with the elderly will not be for everyone.

Aged↗