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PubMed2004

Another look at dreaming: disentangling Freud's primary and secondary process theories.

The Interpretation of Dreams contains Freud's first and most complete articulation of the primary and secondary mental processes that serve as a framework for the workings of mind, conscious and unconscious. While it is generally believed that Freud proposed a single theory of dreaming, based on the primary process, a number of ambiguities, inconsistencies, and contradictions reflect an incomplete differentiation of the parts played by the two mental processes in dreaming. It is proposed that two radically different hypotheses about dreaming are embedded in Freud's work. The one implicit in classical dream interpretation is based on the assumption that dreams, like waking language, are representational, and are made up of symbols connected to latent unconscious thoughts. Whereas the symbols that constitute waking language are largely verbal and only partly unconscious, those that constitute dreams are presumably more thoroughly disguised and represented as arcane hallucinated hieroglyphs. From this perspective, both the language of the dream and that of waking life are secondary process manifestations. Interpretation of the dream using the secondary process model involves the assumption of a linear two-way "road" connecting manifest and latent aspects, which in one direction involves the work of dream construction and in the other permits the associative process of decoding and interpretation. Freud's more revolutionary hypothesis, whose implications he did not fully elaborate, is that dreams are the expression of a primary mental process that differs qualitatively from waking thought and hence are incomprehensible through a secondary process model. This seems more adequately to account for what is now known about dreaming, and is more consistent with the way dream interpretation is ordinarily conducted in clinical practice. Recognition that dreams are qualitatively distinctive expressions of mind may help to restore dreaming to its privileged position as a unique source of mental status information.

Dreams↗
PubMed1980

Time and the dream.

Like the unconscious, a dream is not bound by the constraints of time; as with the unconscious, however, the so-called "timelessness" of the dream is only relative. Both the experience and the concept of time may be present, either openly or implicitly, in the manifest content of the dream. Time as perspective is typically represented in spatial terms, time as duration in terms of motion or situations involving time-bound affects. The concept or experience of time in the manifest dream may signify an unconscious conflict. When time is explicit, the conflict is likely to refer to an early event or relationship; when time is disguised or implicit in the dream experience, it may signify a current conflict, one involving a contemporary relationship or an early relationship reactivated in the transference. By eliminating time perspective, the dream work can make painful affects more tolerable and thus prevent awakening.

Dreams↗
PubMed1987

Falling off the couch.

The patient's therapeutic regression intensifies certain unconscious meanings of the analytic couch. In addition to representing the analysis or the analyst in general, the couch can represent the unconscious, or it may take on the symbolic significance of the analyst's or mother's arms, lap, breasts, or womb. When the genetic roots of the patient's transference include substantial experiences of disappointment, narcissistic injury, and mistrust, the theme of falling from the couch may emerge as a dream, an association, or even an enactment. This theme usually implies the presence of a deepening but mistrustful transference, based on earlier disappointments by the patient's primary objects. Falling off the couch may be associated with being dropped as an infant, rolling out of bed as a child, birth, miscarriage, castration, death, termination, defending against passive wishes, punishment for sexual or aggressive transgressions, escaping an attack, descending into the unconscious, or wanting to be picked up and comforted.

Accidental Falls↗
PubMed1987

Psychoanalytic observations on the effect of lithium on manic attacks.

This paper describes a predictable relation between our manic-depressive patients' blood lithium levels and particular changes in their conscious and unconscious mental processes (i.e., their thoughts, wishes, fantasies, inclinations, and feelings). These changes were, in turn, predictively related to specific changes in these patients' overt manic symptomatology. Because each of our patients' manic episodes was heralded by a marked increase in unconscious or conscious phallic sexual thoughts, feelings, and behaviors, and because this increase preceded any observed deterioration in ego or superego functioning, we hypothesize that a primary increase in our patients' phallic instinctual drives secondarily overwhelmed the capacity of their egos to defend against these drives, and that this, in turn, resulted in the development of our patients' overt manic symptoms. Psychoanalysis (or psychoanalytically oriented psychotherapy) made our patients consciously aware both of their previously unconscious phallic sexual thoughts and impulses, and of their defenses against them. This new awareness enabled our patients to recognize when their, now conscious, phallic sexual impulses and thoughts became inappropriately intensified; and this, in turn, permitted them to avoid overt manic episodes by counteracting these inappropriate inclinations with increased doses of lithium.

Adult↗
PubMed1976

Utilizing reflected countertransference Applying the reflection process as a teaching tool in supervision.

There are times when teaching cannot proceed through the abstract presentation of content and must progress by the demonstration of what is to be taught. This is true whenever a student is unable, for whatever reason, to appropriately apply such abstract material to the concrete task before him. This may be due to a number of factors, one of the most common of which is the lack of qualitatively similar experiences to which to refer. The teaching of complicated processes such as psychotherapy is an example, especially when the trainee is relatively unsophisticated and/or seems unable to abstract from discussion of blocking phenomena, where it may become necessary to "act in" the feeling tones which are to be the cues for the behaviour to be learned, instead of persisting with abstract interpretations. When, in supervision, a supervisee recreates the conditions existing in the therapeutic situation, this procedural behaviour is called the "Reflection Process". This process often appears to be unconsciously motivated by the need of the supervisee to solicit from the supervisor a practical demonstration which he does not know how to solicit otherwise. Even if the Reflection Process is due mainly to unresolved, unconscious conflicts of the supervisee, it can be a useful clue as to what transference-countertransference problems he is having difficulties with. The fact that such behaviour on the part of the supervisee may arise out of unresolved unconscious conflictual material should not become a reason for dismissing it. Instead, supervisors should become proficient at recognizing the countertransferential feelings in themselves, which can be an accurate reflection of the feelings troubling the supervisee in his dealings with this patient; and they should recognize the distress signal on the part of the supervisee, which can often be responded to constructively. In the supervision, the supervisor at times can, almost unwittingly, come to play the role which the supervised therapists plays in the supervised therapy and, if not aware of the Reflector Process, he may not realize that the countertransferential feelings which underly his assuming that role may not be primarily a response to the character of the therapist he is supervising but rather to that of the patient. They may also be a reflection of the process problem in the supervised therapy. It is not essential that this process be labeled in the supervision; what is essential is that its ramifications be recognized by the supervisor.

Allied Health Personnel↗
PubMed2003

Ancestor reverence and mental health in South Africa.

The great majority of South Africa's people consult traditional healers. The deeper meaning of much traditional healing centres on ancestor reverence. This belief system and its accompanying rituals may positively influence the mental health of the individual and the community. Among traditional Xhosa-speaking peoples, the relationship with the ancestors is given expression in life cycle rituals that have much in common with Western psychotherapeutic principles and practices. The common thread that underpins many rituals is that of making links via concrete, literal means. Examples include the participation of the community in the healing of the individual; the linking of body and mind through dancing and drumming. Dreams form an essential connection between conscious life and the unconscious. Understanding the psychological depth of these practices is important so that a respectful relationship between Western-trained professionals and traditional healers can develop. Analytical psychology, with its notion of the collective unconscious has a particular contribution to make to cross-cultural understanding. The ancestors may be understood as archetypal representations of the collective unconscious.

Culture↗
PubMed1995

The influence of Nietzsche on Freud's ideas.

BACKGROUND: The striking analogies between the ideas of Freud and Friedrich Nietzsche, whose works were published from one to three decades before those of Freud, have been commented upon, but no previous systematic correlation of the ideas of Nietzsche and Freud has been made. METHOD: The major works of Nietzsche were read, and each possible analogy to an idea later broached by Freud was correlated by a systematic review of his works. Any references to Nietzsche in Freud's writings and reported conversation were culled. RESULTS: Concepts of Nietzsche which are similar to those of Freud include (a) the concept of the unconscious mind; (b) the idea that repression pushes unacceptable feelings and thoughts into the unconscious and thus makes the individual emotionally more comfortable and effective; (c) the conception that repressed emotions and instinctual drives later are expressed in disguised ways (for example, hostile feelings and ideas may be expressed as altruistic sentiments and acts); (d) the concept of dreams as complex, symbolic "illusions of illusions" and dreaming itself as a cathartic process which has healthy properties; and (e) the suggestion that the projection of hostile, unconscious feelings onto others, who are then perceived as persecutors of the individual, is the basis of paranoid thinking. Some of Freud's basic terms are identical to those used by Nietzsche. CONCLUSION: Freud repeatedly stated that he had never read Nietzsche. Evidence contradicting this are his references to Nietzsche and his quotations and paraphrases of him, in causal conversation and his now published personal correspondence, as well as in his early and later writings.

Austria↗
PubMed2006

Prediction of poor outcome within the first 3 days of postanoxic coma.

OBJECTIVE: To determine the optimal timing of somatosensory evoked potential (SSEP) recordings and the additional value of clinical and biochemical variables for the prediction of poor outcome in patients who remain comatose after cardiopulmonary resuscitation (CPR). METHODS: A prospective cohort study was conducted in 32 intensive care units including adult patients still unconscious 24 hours after CPR. Clinical, neurophysiologic, and biochemical variables were recorded 24, 48, and 72 hours after CPR and related to death or persisting unconsciousness after 1 month. RESULTS: Of 407 included patients, 356 (87%) had a poor outcome. In 301 of 305 patients unconscious at 72 hours, at least one SSEP was recorded, and in 136 (45%), at least one recording showed bilateral absence of N20. All these patients had a poor outcome (95% CI of false positive rate 0 to 3%), irrespective of the timing of SSEP. In the same 305 patients, neuron-specific enolase (NSE) was determined at least once in 231, and all 138 (60%) with a value >33 microg/L at any time had a poor outcome (95% CI of false positive rate 0 to 3%). The test results of SSEP and NSE overlapped only partially. The performance of all clinical tests was inferior to SSEP and NSE testing, with lower prevalences of abnormal test results and wider 95% CI of false positive rates. CONCLUSION: Poor outcome in postanoxic coma can be reliably predicted with somatosensory evoked potentials and neuron-specific enolase as early as 24 hours after cardiopulmonary resuscitation in a substantial number of patients.

Adult↗
PubMed1980

Seizures after head trauma: a population study.

A cohort of 2747 patients with head injuries was followed for 28,176 person-years to determine the magnitude and duration of the risk of posttraumatic seizures. Injuries were classified as severe (brain contusion, intracerebral or intracranial hematoma, or 24 hours of eight unconsciousness of amnesia), moderate (skull fracture or 30 minutes to 24 hours of unconsciousness or amnesia), and mild (briefer unconsciousness or amnesia). The risk of posttraumatic seizures after severe injury was 7.1% within 1 year and 11.5% in 5 years, after moderate injury the risk was 0.7 and 1.6%, and after mild injury the risk was 0.1 and 0.6%. The incidence of seizures after mild head injuries was not significantly greater than in the general population.

Adolescent↗
PubMed1988

Etiology and prognosis of alpha coma.

We reviewed our experience with alpha coma, the finding of predominantly alpha-frequency rhythms in the EEGs of unconscious patients, and identified 50 patients. Cardiac arrest, either inside (n = 25) or outside (n = 24) the hospital, was the cause of unconsciousness in all except one patient who had hyperglycemic, hyperosmolar coma. After out-of-hospital cardiac arrest, the risk of never regaining consciousness or dying during hospitalization did not differ significantly between unconscious patients with (n = 24) and without (n = 69) alpha frequencies in their EEGs. A review of the literature supports our findings that alpha coma most commonly follows cardiac arrest and does not preclude the possibility of neurologic recovery. We conclude that alpha coma is a descriptive term and lacks prognostic significance in itself.

Alpha Rhythm↗
PubMed2006

Factors associated with survival and neurological outcome after cardiopulmonary resuscitation of neurosurgical intensive care unit patients.

OBJECTIVE: We investigated predictors of survival and the neurological outcomes of neurosurgical patients who experienced cardiac arrest and received cardiopulmonary resuscitation after being admitted to the neurosurgical intensive care unit. METHODS: A retrospective study was conducted of adult patients in the neurosurgical intensive care unit who had experienced cardiac arrest and received cardiopulmonary resuscitation. Factors relevant to the cardiac arrest (before and after arrest) were used to study association with survival (immediate or short-term) and neurological outcome (unconscious or conscious) via statistical methods. RESULTS: Immediate survival was seen in 105 patients (49%), 19 survived until hospital discharge, and 11 were still alive at the conclusion of this study. Of the immediate survivors, 41 patients were conscious and 64 were unconscious. Multivariate analysis showed increased mortality in patients with infection, asystole, or resuscitation time exceeding 30 minutes (P < 0.05). Additional factors associated with high in-hospital mortality included lack of spontaneous respiration, no caloric-vestibular reflex, and unconsciousness after resuscitation (P < 0.05). In addition, neurological recovery was poor in patients with infection, asystole, no caloric-vestibular reflex, conscious recovery, or resuscitation lasting more than 30 minutes (P < 0.05). CONCLUSION: Even after initially successful resuscitation, survival and neurological recovery is quite dismal in patients with cerebral lesions. Prognostic factors for neurosurgical patients should be assessed on an individual basis to determine medical futility in the early post-resuscitation period.

Adult↗
PubMed2005

Fear and other disturbances of severe hypoglycaemia in children and adolescents with type 1 diabetes mellitus.

OBJECTIVE: To study perceived occurrence and magnitude of fear and other disturbances of severe hypoglycaemia in children and adolescents with type 1 diabetes mellitus (DM) receiving intensive treatment with active education and psychosocial support. PATIENTS AND METHODS: Out of a geographic population of 112 patients <19 years of age and their families, with a DM duration >1 year, HbA1c mean+/-SD 6.7+/-0.9 (method 1.15% below DCCT level), 74 responded to a questionnaire. Visual analogue scales, 5-graded Likert scales and open questions were used. RESULTS: Global quality of life was high, but lower among patients with severe hypoglycaemia within the last year (p = 0.0114). Worse perceived health was correlated to higher HbA1c year mean (r = 0.32, p = 0.0227). Patients and parents regard severe hypoglycaemia more as a problem (p <0.0001) and the risk of it more disturbing than mild hypoglycaemia (p <0.0001), insulin injections (p <0.0001) or blood glucose determinations (p <0.0001). The disturbance is higher during exercise, disco/party and in travel situations. Severe hypoglycaemia with unconsciousness causes more fear than severe hypoglycaemia needing assistance but without unconsciousness (p = 0.0001) or the potential late complications of DM (p = 0.0014). Severe hypoglycaemia needing assistance but without unconsciousness causes more fear than mild hypoglycaemia (p = 0.0001) and diabetic ketoacidosis (p <0.0001) but less than the potential late complications of DM (p = 0.0034). CONCLUSIONS: Severe hypoglycaemia frequently causes fear and various disturbances in spite of active education and psychosocial support. There is a potential for increased quality of life from interventions targeted at the prevention of severe hypoglycaemia. Further research and improved strategies for the prevention of severe hypoglycaemia are needed.

Adolescent↗
PubMed2000

Reflections on psychic reality.

The author explores the nature and development of psychic reality and draws the following conclusions: (1) psychic reality is equivalent to subjective (conscious) awareness. (2) Psychic reality is open to unconscious influences, both as to content and motivation. Psychic reality thus is not equivalent to unconscious fantasy or transference, but can include effects of both. (3) Psychic reality can also include objective experience. (4) The capacities for internal psychic experience and knowledge of objective reality externally are modes of experiencing that develop early and achieve gradual integration through integrative play. (5) Psychic experience, and therefore psychic reality, cannot be regarded as exclusively subjective or objective, but as inherently both. The ways in which subjectivity does not preclude or exclude objectivity are discussed and related to transitional experience. (6) The inherent subjectivity of psychic experience precludes any form of direct intersubjective communication, that is, unmediated communication from subject to subject. The tensions of subjectivity and objectivity are discussed in relation to the analytic situation, in which perspectives of patient and analyst differ and reflect their respective psychic realities, each with its own validity and uncertainty and openness to unconscious needs, fantasies and motives.

Awareness↗
PubMed2004

The seventh servant: the implications of a truth drive in Bion's theory of 'O'.

Drawing upon Bion's published works on the subjects of truth, dreaming, alpha-function and transformations in 'O', the author independently postulates that there exists a 'truth instinctual drive' that subserves a truth principle, the latter of which is associated with the reality principle. Further, he suggests, following Bion's postulation, that 'alpha-function' and dreaming/phantasying constitute unconscious thinking processes and that they mediate the activity of this 'truth drive' (quest, pulsion), which the author hypothesizes constitutes another aspect of a larger entity that also includes the epistemophilic component drive. It purportedly seeks and transmits as well as includes what Bion (1965, pp. 147-9) calls 'O', the 'Absolute Truth, Ultimate Reality, O' (also associated with infinity, noumena or things-in-themselves, and 'godhead') (1970, p. 26). It is further hypothesized that the truth drive functions in collaboration with an 'unconscious consciousness' that is associated with the faculty of 'attention', which is also known as 'intuition'. It is responsive to internal psychical reality and constitutes Bion's 'seventh servant'. O, the ultimate landscape of psychoanalysis, has many dimensions, but the one that seems to interest Bion is that of the emotional experience of the analysand's and the analyst's 'evolving O' respectively (1970, p. 52) during the analytic session. The author thus hypothesizes that a sense of truth presents itself to the subject as a quest for truth which has the quality and force of an instinctual drive and constitutes the counterpart to the epistemophilic drive. This 'truth quest' or 'drive' is hypothesized to be the source of the generation of the emotional truth of one's ongoing experiences, both conscious and unconscious. It is proposed that emotions are beacons of truth in regard to the acceptance of reality. The concepts of an emotional truth drive and a truth principle would help us understand why analysands are able to accept analysts' interpretations that favor the operation of the reality principle over the pleasure principle--because of what is postulated as their overriding adaptive need for truth. Ultimately, it would seem that Bion's legacy of truth aims at integrating finite man with infinite man.

Adult↗
PubMed2006

Further reflections on the impact of clinical writing on patients.

Though it is unlikely that instituting universal guidelines will ever be possible for patient approval of the analyst's use of clinical material outside of the treatment setting, the author offers some supplementary reflections to those already available in the literature. Broadly applied informed consent guidelines would increase the distortion that already exists in our clinical literature due to self-imposed restraints by writers. Moreover, the powerful irrational forces mobilized by consent in the dyad are not easily 'held' by traditional applicable legal categories. Metapsychological formulations of the intrapsychic and intersubjective impact of patient participation in the writing process on individual analytic dyads are needed. Notions of privacy protection, validation, dyadic co-construction, or writing-as-containment by a third as rationales for informed consent fail to encompass the transindividual and external sources of human identity and the ineradicable lack of unity in the unconscious. Nevertheless, theoretical affinity and preferred technique may be mediating factors in positive outcomes of the consent process. Some paradigms not only accommodate more comfortably but also actively seek the intersubjective repercussions of informed consent. As an alternative or complementary viewpoint, the author offers the hypothesis that the clinical ramifications of either disguise or consent are not exclusively, nor even necessarily, concerned with what patients read about themselves, but what they assess or intuit--directly or indirectly through the material presented--of their analyst's unconscious strivings. To truly triangulate the clinical reporting project, it is wisest to consult the third ear of a colleague to assess the potential impact on patients on what might be being unconsciously transmitted by the analyst in the writing and the consent process.

Confidentiality↗
PubMed2005

Joining a group's task: the discovery of hope and respect.

When engaged with others in tension-filled dialogue, the temptation is for us to treat the other disrespectfully by unconsciously choosing an exclusive subgroup in our minds to belong to, and assigning the other to a devalued group. Unconsciously asserted exclusive membership allows us to deny the ways in which, by disconnecting the other, we are also alienating parts of ourselves. Using three stories, the author explores the notion of unconscious group membership and raises the possibility of discovering a shared membership in the midst of conflict. Internalized shared group membership can constitute a mediating "third" to a dyad in apparent opposition. The shared internal context both contains and defines the pair within a task and set of values that can be used to transcend apparent conflict.

Culture↗
PubMed1991

Somatic correspondences during psychoanalysis.

Somatic as well as cognitive correspondences occur during psychoanalytic treatment. The somatic type have received little, if any, attention from the analytic community, at least in terms of published references. Somatic symptom(s), activated by external events in his or her life, first appear in the analyst. Almost immediately thereafter identical or closely similar experiences appear in the analysand and (during the treatment hour) are verbalized by him or her. Should attempts to understand correspondences stop at this point, it is easy to conclude they are due to mere coincidence, but they have deep, unconscious roots. Analytic exploration of these roots reveals practically simultaneous occurrence of certain activated conflict residues in the analyst and comparable ongoing but far less worked-through conflict areas in the analysand. The brief interval when these activated facets become approximate in intensity appears to be the trigger for the correspondence. Preoedipal aspects of unconscious conflict are more apt to be reflected in somatic correspondence, whereas oedipal aspects are more likely to be expressed in cognitive correspondence. In any event, data available from the case material reported suggest that from a psychological point of view the unconscious plays a significant role in extrasensory and unverbalized communication and suggest addition of the concept of body-language transference to that of thought transference.

Adult↗
PubMed1984

Early alcoholism treatment: the Emmanuel Movement and Richard Peabody.

The history of alcoholism treatment in the early twentieth century is outlined. The methods of the Emmanuel Movement and of Richard Peabody are described, biographical details of their main practitioners are given, the populations treated are described, and the predecessors and successors of the two methods are discussed. In addition, the two methods are compared with each other and with the methods of Alcoholics Anonymous and Freudian psychoanalysis. The founder of the E. Movement was a clergyman, Dr. Elwood Worcester, whose method was designed to treat a variety of neurotic disorders. He felt that all diseases, including alcoholism, had physical, mental and spiritual components. His principal techniques of relaxation therapy and suggestion (including autosuggestion) were used to reach the unconscious. Worcester felt that alcoholics could be helped by redirecting their attention away from their problems to a life of service and spirituality. Prayer, group support and self-help were important. Worcester tried to reduce patients' guilt and rejected temperance preaching. He felt that recovery must come from surrender to external forces and to the healing capacities of the unconscious. One patient of his, Courtenay Baylor, began to work with him at the E. Church. Like Worcester, Baylor believed that alcohol, and not one's life history, caused alcoholism. Baylor believed that alcoholism resulted from mental and physical "tenseness" and, like Worcester, he used relaxation therapy. He believed in giving a longer period of treatment than did Worcester and in providing more treatment for the families of alcoholics. One of Baylor's most famous patients was Peabody. Peabody had no credentials but he refined and professionalized the E. treatment method. He was a strong believer in the control of one's feelings and in increased efficiency--his patients were told to follow detailed time plans. He believed that early family history caused alcoholism. Like the E. Movement, he felt that relaxation, suggestion and catharsis were important. Unlike the E. Movement, he regarded the unconscious as an obstacle. His method was also less spiritual. His philosophy seemed to have been derived from the mind-cure movement, including New Thought; he was not interested in the body. The fact that the practitioners of the Emmanuel and Peabody methods were not physicians is discussed. The treatment success of both methods is unclear.

Alcoholism↗