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PubMed1994

Object constancy and adult psychopathology.

In this paper, the author has summarised Mahler's views on the initial acquisition of object constancy in early childhood. He then attempts to delineate its vicissitudes during oedipal phase, latency, adolescence, and various phases of adult development. Following this, the author describes, with the help of brief clinical vignettes, six psychopathological syndromes of adult life associated with disturbed object constancy: (i) impaired optimal distance; (ii) persistent splitting of self- and object-representations, with the concomitant intensification of affects; (iii) paranoia; (iv) inordinate optimism and the 'someday' fantasy; (v) malignant erotic transference; and (vi) impaired capacity to mourn, intense nostalgia and the 'if-only' fantasy. Finally, the author outlines the technical implications of these concepts and attempts to show that six tasks seem especially important for analytic work with such patients: (i) safeguarding the analyst's 'holding' function; (ii) interpreting splitting mechanisms, especially as these pertain to negative transference; (iii) maintaining optimal distance; (iv) discerning nonverbal communications, especially through countertransference; (v) encouraging developmental initiatives; and (vi) facilitating mourning, not only of past losses but also of those inherent in the analytic situation. Through all this, the author attempts to highlight, elucidate and extend modestly the work of Margaret Mahler.

Adult↗

PubMed1994

On limit and limit setting.

This article investigates the role of limit and limit setting within the psychoanalytic situation. Limit is understood to be a boundary between self and others, established as an interactional dimension of experience. Disorders of limit are here understood within the context of Winnicott's conception of the "anti-social tendency." Limit setting is proposed as a necessary and authentic response to the patient's acting out via holding and empathic responsiveness, viewed here as a form of boundary delineation. It is proposed that the patient attempts to repair his or her boundary problem through a seeking of secure limits within the analyst. The setting of secure and appropriate limits must arise from a working through of the analyst's own countertransference response to the patient. It is critical that this response be evoked by, and arise from, the immediate therapeutic interaction so that the patient can experience limit setting as simultaneously personal and authentic.

Adolescent↗

PubMed1994

[The problem of suicide in neurologic rehabilitation].

Associations between somatic as well as, in particular, neurological diseases and suicidal acts are outlined, with studies of different diseases having shown that they represent only one factor in motivating the suicidal act. Biographical predispositions and stressful variables from the current social situation are always added. Depressive and organic brain syndromes that can often be found during neurological rehabilitation are discussed in their significance as risk factors for suicidal behavior, also seeking to identify distinct phases of the rehabilitation process afflicted with high suicide risk. An active and carefully directed approach to exploration as well as grasping the psychopathological symptomatology are fundamental elements in the assessment of suicide risk. In this respect, observations of the patient's behaviour and information obtained from relatives are of special importance in neurological rehabilitation clinics. The "presuicidal syndrome" (Ringel) continues to be of high clinical value in assessing the psychodynamics of the individual patient in his development towards the suicidal act. Reflections of suicidal tendencies in countertransference reactions and the communication pathology of suicidal behaviour are more recent aspects that enrich the assessment of suicide risk. Therapeutic management of suicidal patients can firstly be characterized by the principle of specific diagnosis and treatment of the underlying disease; this means that optimum medical care even has a suicide-preventive function. The other principle considers the establishment of a therapeutical relationship as a must, and some critical points in the personal contact with suicidal patients are dealt with in some detail. Especially in neurological rehabilitation clinics, custodial aspects must not be neglected.(ABSTRACT TRUNCATED AT 250 WORDS)

Brain Damage, Chronic↗

PubMed1976

[Speech behavior and neurotic personality structure (author's transl)].

Speech behavior of the patient and the analyst is considered with regard to the psychoanalytic situation and its regulating factors such as transference and countertransference. If the psychoanalytic situation is regarded as a means to investigate the patient and his symptoms, his verbal behavior seems to depend on the unconscious motives forming his neurotic personality structure. On the other hand, if the psychoanalytic situation is regarded as a communicative situation, the verbal behavior of the patient as well as of the analyst depends rather on their "here-and-now" transference relationship in certain phase of the psychoanalytic process.

Adult↗

PubMed1993

Evaluating the best interests of the child--a model of multidisciplinary teamwork.

This article describes the rationale, goals and procedure of a working model of multidisciplinary teamwork in conducting clinical evaluations of children and families and preparing expert testimony. Over the past five years, the team has evaluated over 60 cases involving child abuse and neglect, and questions of parental ability. Teamwork can reduce the distorting effects of personal biases, beliefs and countertransference issues. The contribution of integrating different theoretical viewpoints (theories of development, object relations, family systems, etc) is discussed. Recommendations include: (a) separation of roles of expert witness and therapist: (b) utilization of different diagnostic tools (psychodiagnostic tests, observations of interaction, joint clinical interviews, etc); (c) value of examining the feasibility of the recommendations with parents, care givers and community workers; and (d) strategies of dispute resolution and attainment of parental consent, utilizing the effects of potential judicial power and focusing on the best interests of the child.

Child↗

PubMed1993

[Psychophysiologic manifestations, psychological and somatic risk factors and the physician-patient relationship in patients with heart diseases].

In daily medicine we often see patients complaining about thoracic pain. There is little doubt about the etiology in the most cases, but several patients continue posing diagnostic problems. There are different pathophysiological views to understand the situation of those patients, and it is important to determine their mental and psychological conditions. For this purpose, the focus on transference and countertransference phenomena has to be stressed. With these elements it will be possible to determine the diagnostic and therapeutic approach to those patients to reassure them and to justify investigations.

Adult↗

PubMed1993

What is psychoanalysis now?

Firstly, Freud's classical statement that every treatment that takes into account the phenomena of transference and resistance deserves the designation psychoanalysis is critically examined in a current, post-classical context. The confusion as a consequence of the fact that two different concepts of transference are often used indiscriminately is elucidated. Likewise, the dynamic conditions of two types of resistance--the classical type, as a result of internal conflict, and the interactional type, having to do with empathic failure and countertransference--are disentangled and related to current ideas on two types of conflict, convergent and divergent. This is technically reflected in the understanding of two types of therapeutic action: a nonverbal, object-relational factor as distinguishable from the effect of insight and interpretation. Finally, the dialectics of insight and relation are theoretically clarified through the clinical concepts of background and foreground, which are clinically bound to the concrete psychoanalytical situation and form a tool to distinguish the two types of transference, resistance and conflict.

Defense Mechanisms↗

PubMed1993

Some reflections on humour in psychoanalysis.

This article proposes that for humour to be effective as a therapeutic intervention in psychoanalytic treatment, it must approximate an affect releasing and growth promoting interpretation. The presence and psychological significance of surprise, which is common to both wit and 'good' interpretations, is taken as the point of departure and the importance of the psychoanalyst's spontaneity is discussed in relation to this. The author explains his opposition to the use of humour as a contrived communication: as a parameter aimed at reviving a dying analysis or as an attempt to resolve an impasse. In particular the dangers of countertransference acting out the provision of transference gratifications are explored. Equal emphasis is placed on recommending that the analysis of a patient's humorous responses should not be neglected and how an analyst without humour may negatively affect the treatment process. The paper includes clinical vignettes which illustrate the constructive and creative use of humour in the analytic situation.

Borderline Personality Disorder↗

PubMed1993

Male or female therapists for eating-disordered adolescents: guidelines suggested by research and practice.

The question of whether male or female therapists are best for female patients has sparked controversy for decades. This paper explores which therapist-patient gender matches facilitate the most patient growth and avoid detriment to female patients. There is little research on this subject related to eating-disordered female adolescents. Thus, an attempt was made here to distill relevant variables from the literature on eating disorders, adolescence, transference and countertransference, and psychotherapy, as well as the author's own practice, to suggest guidelines for effective matches. Although no consistent evidence pointed to a particular match as being most effective in this population, situations are noted in which assignment of one gender offers the chance of better therapeutic alliance. Therapist and patient preferences, the patient's traumatic experiences, enmeshed versus disengaged patient relationships, patient resistance, and therapists' comfort with both their male and female sides are variables related to preferred assignment. Advantages and disadvantages for male and female therapists are discussed, and suggestions made for variables to be used in future studies.

Adolescent↗

PubMed1993

Aggression and the psychological self.

In this paper we explore the idea of aggression as a defence against threats to the psychological self. This aspect of the self allows reflection about people in psychological terms and develops, in the first three years of life, through appreciation of mental states in the other. When the object is unpredictable or hostile, recognition of this is painful to the child, and his reflective function will not be adequately established. The defences of aggression or avoidance will be invoked very frequently. In time, aggression may become an organising influence in the construction of the self; pathological destructiveness then takes the place of emotional relatedness and concern for the other. Psychoanalytic treatment no longer works primarily by addressing conflict. Instead, particularly through interpretations of transference and countertransference, the analyst recreates an intersubjective process which enhances the patient's reflective self, this time in the safety of a benign relationship.

Adult↗

PubMed1993

The analyst's pregnancy: the patient, the analyst, and the space of the unknown.

In this paper I have discussed some thoughts about the effect of the analyst's pregnancy on her patients, using material from my own experience. In the first part of the paper I have examined some of the issues evoked in the countertransference especially in the first trimester of pregnancy, when, because of my concern about the health of the foetus I was reluctant to inform patients of my state. In the latter part of the paper I have focused on some of my patients' responses as expressed in the transference: in particular on the question of how patients dealt with learning of and thinking about my pregnancy, which involved a threat to the sense of unity, fusion and non-separateness from me that in some cases were of paramount importance. To do this I have discussed at some length clinical material relating to two patients, the first a woman whose own pregnancy followed mine, in an imitative fashion that both denied any difference between us and also allowed her to develop her capacity to be a mother; the second a man who initially understood my pregnancy as rejecting of him, persecuting and guilt-provoking, and saw it as an event either unthinkable and/or to be dealt with omnipotently.

Acting Out↗

PubMed1993

Theoretical difficulties in the treatment of mentally ill prisoners.

Work as a psychiatrist in a correctional setting involves a difficult interface of the theories of psychiatry, the law, and corrections. The coexistence of models of punishment, rehabilitation and mental health treatment in this work create ethical and practical challenges for the psychiatrist. The lack of a singular or clear theoretical framework may contribute to a potential for countertransference issues to play a determinant role in psychiatric decisions. These difficulties are based on the intersection of the theoretical issues involved.

Humans↗

PubMed1993

Whose body is it anyway? Understanding and treating psychosomatic aspects of eating disorders.

Eating disorders can be understood as psychosomatic illnesses in which the body is pitted against the psyche. The author explores a variety of theoretical principles that aid understanding of the eating disorders and inform treatment interventions. She explains various therapeutic interventions and discusses countertransference difficulties that may hinder work with eating disorder patients. A theoretical understanding of the nature of psychosomatic dissociation in these patients enables treaters to understand why treatment often takes a very long time and is met with strong resistance even as the patient clamors for help.

Adolescent↗

PubMed1995

[Are "behaviorally disordered" migrant children of "noncompliant" parents treatable? Interdisciplinary cooperation between system-oriented school psychology and psychoanalytically oriented therapy].

This case presentation describes the cooperation between experts of different basic training and theoretical provenance. A system oriented school psychologist takes on the 'case' of a massively behaviourally abnormal, aggressive, and marginalized girl of working migrants from the lower stratum, prepares the way for psychotherapy and transfers the treatment to a psychoanalyst. In this case the role of the school psychologist consists of receiving a crisis situation which is slipping out of hand and redefining the problems with all parties involved. By expanding the perspective to the context of school-family-immigration society contradictions and breaks become evident. The culture shock of the first migration phase was reinacted by the parents in the difficult confrontation with the Swiss institutions. In contrast to psychosocial sees the contradictions as being logical-congruent and tries to build bridges and activate change. The transformation of rigid reality constructs is furthered and psychotherapeutic treatment is mediated, explained and accompanied during the process. The role of the psychoanalyst consists of taking up the relationship to the girl and establishing a serviceable working relationship with the parents. She has to recognize the girl's inner and unconscious conflicts which are actualized in transference and countertransference in the therapeutic process. After empathetic interpretative work she offers new forms of dealing with conflicts which take the girl's outer reality (family, school, migrant situation, cultural reality) into consideration. Accompanying the parents intensively at the same time broadens their competence in raising their daughter. In this case the neurotic developmental disorder is strongly connected with the migration problem.

Acculturation↗

PubMed1996

Women and trauma: a contemporary psychodynamic approach to traumatization for patients in the OB/GYN psychological consultation clinic.

Many patients referred to an OB/GYN psychological consultation clinic were found to be suffering from the emotional effects of early traumatization. Obstetrical and gynecological conditions possess a unique power to reactivate psychological damage originally engendered by trauma. A contemporary psychodynamic model of trauma and its sequelae proved useful in intervening psychologically and in helping these patients and their physicians to improve the management of their medical conditions. This model represents an effort to integrate: (1) Herman's (1992) conception of complex posttraumatic stress disorder, (2) character development in individuals with early traumatic experiences, and (3) Weiss and Sampson's (1986) formulations regarding "unconscious pathogenic beliefs"-the dread that one's worst unconscious fears will be confirmed. Two clinical cases-a pregnant teenager and a woman with hyperemesis gravidarum (excessive and persistent vomiting in pregnancy)-illustrate the frequent emergence of transference-countertransference dynamics centered around "blaming the victim" in work with these patients. Suggestions for therapeutic interventions in short-term consultation with these patients are articulated.

Adolescent↗

PubMed1995

Considerations on anatomical and psychic reality in relation to an intersexual patient.

On the basis of a clinical account of the analysis of an intersexual patient, the author discusses theories of sexual identity and psychosexuality in terms of the impact of bodily and other aspects of factual reality on psychic reality. She considers the extent to which a subject's fate is determined by anatomy and emphasises the importance of such factors as sexual assignment at birth. The fluctuations in Freud's views on female psychosexuality are examined in detail and it is pointed out that in his writings anatomy is always mediated by psychic reality. A critical review of later authors' theories of sex and gender then follows. Turning to her case history, the author describes the implications of her insistence, partly as a manifestation of countertransference disavowal, on seeing her patient as a woman despite the latter's self-presentation as a hermaphrodite. The significance of the patient's homosexuality is discussed and an account is given of her development in the analysis. Aspects of anatomy, bisexuality and identity are reviewed and the paper ends with a further consideration of the treatment of sex and gender in Freud and other authors leading to ideas on the role of the drives and the importance of the sexual element in identity.

Adult↗

PubMed1995

Prototypical expectations of safety: a developmental approach to the assessment of the psychoanalytic process.

The author proposes that developmental research into the main experiential components of internal working models and process research into central patterns of interaction between analyst and patient may share similar theoretical assumptions. A developmental hypothesis bridging these two areas of research is proposed, in which repeated success or difficulty in mutual regulation during infancy result in an emotionally charged set of 'prototypical expectations' that continually influence the sense of personal safety. The author argues that prototypical expectations interfere in the psychoanalytic process because they allow the defensive warding off of negative expectations and so parallel explorations of new relational solutions. An analysand's narratives can be considered to express the conflict between negative transference (generally expressed in relation to extra-transference interactions) and defensive positive transference (more likely to be explicitly connected with the therapeutic situation). During the analytic process, ambivalent transference should appear in both 'worst' and 'best' types of narrative as an indication of warded-off negative transference working through. In this paper an application of the negative prototypical expectations processing hypothesis is presented through a formal discussion of the relational structure of the narratives of a 17-year-old boy's first four analytic sessions. The author demonstrates that this hypothesis makes it possible to predict the transference and the countertransference topics with which the patient and the analyst will have to cope during the treatment.

Adolescent↗

PubMed1977

[Psychopharmacology and psychotherapy: a dynamic therapeutic parallelism to be integrated].

In a brief expose, the author wants to integrate the psychoanalytic data towards a better clinical use of psychopharmacology. Starting from a triadic situation "patient-physician-medication", he proposes a dynamic rather than a static attitude in the patient's approach, aiming at an eventual diadic relation "patient-physician" and, if at all possible, a relative or total independance of the patient. After alluding at the role of the physician, of the patient and of the medication, in such a process, the author refers to intra and extra psychic influence in disease. The concepts of "team approach" and "milieu therapy" are related to the key-role of the psychiatrist and to the availability of competent and well-motivated paramedical professionals in sufficient numbers. The notions of transference, countertransference and control as well as the symbolic of the symptoms are briefly outlined. The author concludes that the complementary elements of psychoanalysis and psychopharmacology will benefit the patient if the clinician knows how to integrate them along with the changing and dynamic process of the illness.

Humans↗