Saying the right thing at the right time: a view through the lens of the analytic process scales (APS)

Skillful psychoanalytic technique presumably involves knowing what to say, and when and how to say it. Does skillful technique have a positive impact upon the patient? The study described in this article relied on ratings by experienced psychoanalysts using the Analytic Process Scales (APS), a research instrument for assessing recorded psychoanalyses, in order to examine analytic interventions and patient productivity (greater understanding, affective engagement in the analytic process, and so on). In three analytic cases, the authors found significant correlations between core analytic activities (e.g., interpretation of defenses, transference, and conflicts) and patient productivity immediately following the intervention, but only if it had been skillfully carried out. Findings were independently replicated by psychology interns.

Writing about patients: IV. patients' reactions to reading about themselves

When analysands read about themselves in reports, their reactions range from anger, disappointment, or condemnation to a sense of appreciation or even idealization of the analyst. The eleven interviews reported here reflect only conscious responses; the unconscious layers were not probed for. It should be kept in mind also that the analysts of these patients might report very different stories. Other limitations are the small sample size and the representation only of patients who volunteered. Nonetheless, the information they provide may help analysts consider how and when writing about patients may influence their representation of themselves, the analyst, and analysis itself.

The impossibility of forgiveness: shame fantasies as instigators of vengefulness in Euripides' Medea

Unforgivability in Euripides' Medea is explored in the context of intrapsychic forces favoring disruption and narcissistic withdrawal and precluding the influence of forces favoring repair of bonds, not necessarily to the betrayer, but to the social and moral order. The forces underlying disruption and withdrawal operate to such an extent that forgiveness and cooperation with the social order become impossible. Euripides' literary insights are explored with the purpose of deepening and extending the psychoanalytic understanding of shame, shame fantasies, projective identification, and vengefulness as they bear on the problem of forgiveness. Three types of shame fantasy are pertinent to the transformation of Medea's mental state from one of anguished and disjointed shame to diabolical vengefulness: anticipatory paranoid shame, the projective identification of shame, and withdrawal as a defense against shame.

Writing about patients: V. analysts reading about themselves as patients

The narratives of twenty analysts written about when they were patients are presented. Their stories provide suggestions about practices to avoid when writing clinical material, but no generalized prescriptions emerge. Individualization and sensitivity to the situation for each pair remain the best guide. The experiences these analysts recount run the gamut of emotions, from negative through neutral to positive. The neutral responses came mainly from twelve analysts who in the course of an interview about their own writing told of having been written about as patients. The other eight, volunteers who initiated contact for the sole purpose of reporting their experience of having been written about, appear on average to be motivated by stronger affective reactions. The era in which the analyst wrote also seems to have influenced the reactions; in earlier times, not asking permission was accepted professional practice. Today, however, it is increasingly common to ask permission when extended clinical examples are published. One problem specific to analyst-patients was concern about the loss of their role as patient when their analyst engaged them collaboratively in the writing.

Strategic self-marginalization: the case of psychoanalysis

Marginality is an important concept in the history of science, though it is often used in a manner that presumes marginality to be a static designation. We contend that the dynamics of marginality are crucial to the history of psychoanalysis, a discipline that has moved between dominant and marginal positions. We address psychoanalytic marginality via three specific "cases": the marginalization among Freud and his followers when psychoanalysis was an emergent discipline; the marginality trope in Erich Fromm's popular psychoanalytic writing when psychoanalysis was orthodoxy in American academic psychiatry; and the rhetorical marginality of psychoanalysis in Sweden as psychoanalysis entered a decline within psychiatry. Our aim is to show that marginalization and self-marginalization serve interpersonal, social, and professional strategies.

Was the gender identity disorder of childhood diagnosis introduced into DSM-III as a backdoor maneuver to replace homosexuality? A historical note

Over the years, the DSM diagnosis of gender identity disorder (and its predecessors gender identity disorder of childhood [GIDC] and transsexualism) has attracted controversy as a mental disorder, for its diagnostic criteria, as a target of therapeutic intervention, and for its relationship to a homosexual sexual orientation. Another point of controversy is the claim that the diagnosis of GIDC was introduced into the DSM-III in 1980 as a kind of "backdoor maneuver" to replace homosexuality, which was deleted from the DSM-II in 1973. In this article, we challenge this historical interpretation and provide an alternative account of how the GIDC diagnosis (and transsexualism) became part of psychiatric nosology in the DSM-III. We argue that GIDC was included as a psychiatric diagnosis because it met the generally accepted criteria used by the framers of DSM-IIIfor inclusion (for example, clinical utility, acceptability to clinicians of various theoretical persuasions, and an empirical database to propose explicit diagnostic criteria that could be tested for reliability and validity). In this respect, the entry of GIDC into the psychiatric nomenclature was guided by the reliance on "expert consensus" (research clinicians)--the same mechanism that led to the introduction of many new psychiatric diagnoses, including those for which systematic field trials were not available when the DSM-III was published.

Affects, agency, and self-regulation: complexity theory in the treatment of children with anxiety and disruptive behavior disorders

In an increasingly unsettled and violent world, with swelling numbers of children who are abused, abandoned, or neglected, emotionally if not physically, and an increasing population of aggressive preschool children with anxiety and disruptive behavior disorders who cannot be contained in ordinary settings, psychoanalysts can make a contribution. Early intervention is essential. In very early childhood, new procedural memories for interacting with others and for regulating affects can be formed more easily than they can ever be again. Intervention should aim toward helping the child develop a sense of agency, establish moral standards, assume self-responsibility, and attain the capacity for emotional regulation. The principles of complex dynamic systems can inform psychoanalytic treatment strategies, as demonstrated with five children whose cases are presented.

How to play with patients who would rather remain remote

Playful technique with negativistic, schizoid patients is described and further explained. They are seen as closing their mind, imagination, needs, and feelings to protect themselves against the terrifying dangers of human relatedness (vulnerability, need, hurt, loss, fusion, destruction). The analyst, while respecting the schizoid patient's need for protection, affirmation, and validation, seeks creative ways of engaging the patient more closely. Playful technique with schizoid patients combines the analyst's sensitive, playful attitude with an invitation to playful action as an experiment with new feelings, longings, hopes, and expectations. Playful engagement is one technique for attempting to engage patients not now open to verbal interpretation. To succeed with such patients, the analyst needs to connect with the core of their protectiveness and thereby come to enjoy their defensive powers, tolerate their need of the analyst, and not feel insulted. The analyst's light, playful approach to these patients' life-and-death terrors of hating and loving aims to show them that they have grossly exaggerated the powers of their hatred and their love.

Remarks on the history of the terms "object representation" and "self representation"

This paper reconstructs the history of the term "object representation" and "self representation". It seeks to show that "Objektrepräsentanz" was introduced by Fenichel in 1926, following on from Radó, in order to be able to integrate identification (and the superego) into metapsychology. Freud himself never used "Objektrepräsentanz". Fenichel's pioneering role is not discernible in the English literature mainly because of the diverging approaches used in the translation of this term (object representative versus object representation). It is generally acknowledged that "self representation" was first used by Hartmann but this paper suggests that it actually played a more crucial role in Jacobson's work than it did in Hartmann's. In addition, this paper sees the terms of self and object representation as a reflection of the paradigm change in the 1920s that ensued after the publication of Freud's "The Ego and the Id". In tracing the history of the terms, the significance of the Berlin Psychoanalytical Institute in the 1920s emerges as do the Berlin roots of the works written in the USA in the 1950s and 1960s by Edith Jacobson. She received her analytical training in Berlin. Fenichel was her analyst, Radó was one of her teachers, and she was closely involved with the work of her fellow analysts there.

Changes in representations of a self-designated significant other in long-term intensive inpatient treatment of seriously disturbed adolescents and young adults

Blatt and colleagues (1996) found that severity of psychopathology in seriously disturbed, treatment-resistant, hospitalized adolescents at the beginning of treatment was positively correlated with the degree to which these adolescents were involved in describing their parents. At the end of long-term, intensive, psychodynamically oriented, inpatient treatment of these very troubled adolescents, reduction in the severity of psychopathology correlated significantly with increases in the development of the structural organization of descriptions of mother, father, self, and therapist. These findings suggested that treatment of seriously disturbed, treatment-resistant, adolescent and young adult inpatients seems to involve at least two primary dimensions: 1) disengagement from an intense involvement with parents and 2) development in the structural organization of representations of self and a significant new figure, the therapist. The present study extends these earlier findings by examining changes in the description of a "significant other" that each patient elected to describe at the beginning and the end of treatment. Clinical improvement over the course of treatment was significantly correlated with developmental progression of the significant figure each patient selected to describe (from a grandparent to a close friend) as well as with progression in the developmental organization in which this significant other was described. These findings suggest that treatment of seriously disturbed adolescents and young adults involves a disengagement from an intense involvement with primary caregivers to involvement with others outside the family matrix and the developmental elaboration of the representation of these figures.

The capacity to forgive: intrapsychic and developmental perspectives

The topic of forgiveness, despite its importance for the continuity of relationships and for the mental health of the aggrieved party, is relatively neglected in the psychoanalytic literature, perhaps because it is often seen as the province of religion and carries the connotation of reaction formation and inauthenticity. However, genuine forgiveness involves significant intrapsychic work, conscious and unconscious working through of one's anger, and putting the offense into the context of an integrated view of the whole person of the offender. Early developmental structures are the ground on which the relative ability to let go of a grievance depends. While later motives and defenses (e.g., fear of retraumatization, avoidance of shame) may also play a role, these early structures are primary. They are described here in terms of attainment of the depressive position and the development of a sense of secure attachment, the capacity to mentalize, and the ability to mourn.

The "something more" than interpretation revisited: sloppiness and co-creativity in the psychoanalytic encounter

Features of dynamical systems thinking can illuminate insufficiently recognized levels of psychoanalytic process. A central aspect of dynamical models is that changes in complex systems are unpredictable and arise out of the interaction of elements. Examination of the moment-by-moment micro-foreground, or local level, of psychoanalytic sessions led to the conclusion that indeterminacy and surprise are inherent properties of intersubjective systems. This indeterminacy, or sloppiness, comprises several interrelated features of the dialogue: "fuzzy" intentionalizing, unpredictability, improvisation, variation, and redundancy. Audiotaped transcripts of two analytic sessions illustrate how these sloppy features generate unpredictable and potentially creative elements that contribute to psychotherapeutic change.

The struggle to listen: continuing reflections, lingering paradoxes, and some thoughts on recovery of memory

This paper offers a further expansion of the author's continuing endeavor to highlight and explore subtle distinctions and lingering paradoxes in how we listen, and to reconsider their profound implications for clinical work and discovery. Several perhaps commonplace clinical moments are used to sharpen illumination on psychic experience that might otherwise remain outside conscious awareness, whether in the domain of the repressed or in other mnemonic realms, such as "implicit" or "procedural" memory. It is suggested that added dimensions of these different levels of memory may, through our struggle to listen, be ultimately knowable.

Marginal historiography: on Stekel's account of things

Psychoanalytic historiography has been, and to a certain extent still is, written mainly from the victor's (Freud's) perspective. One of the first attempts to deliver an alternative account was published in 1926 by Wilhelm Stekel in a little-known paper entitled "On the History of the Analytical Movement," which he wrote in response to Freud's (1925) "An Autobiographical Study" as an attempt to supplement or even counter Freud's version. This paper offers a dialogical reading of Stekel's paper, focusing not on the question of whether or not Stekel was right, but on the problem of marginalization itself. What discursive processes contributed to the marginalization of Stekel's position, and in what sense could Stekel's paper be called an instance of self-marginalization? Analysing various intertextual links between Freud's and Stekel's accounts, the author finds that the two accounts were caught up in an antagonistic dialectic from which it was impossible to escape. Following this paper, an English translation of Stekel's 1926 account is presented here for the first time.

Magical arts: the poetics of play

The paper argues that links between play and magic in British Object Relations point to the persistence of aesthetic concerns within psychoanalysis. Magical thinking is present in British Object Relations psychoanalysis from its beginnings in Klein's play technique and early aesthetic writings, surfacing elsewhere in Susan Isaac's educational experiments and her theories of metaphor. Marion Milner's clinical account of the overlapping areas of illusion and symbol-formation in a boy's war-games link the primitive rituals of Frazer's "The Golden Bough" with her patient's creativity. In Winnicott's concept of the transitional object, the theory of play achieves its apotheosis as a diffusive theory of culture or "private madness," and as a paradigm for psychoanalysis itself. Tracing the non-positivistic, mystical, and poetical elements in British Object Relations underlines the extent to which aesthetics is not just entangled with psychoanalysis, but constitutive of it in its mid-twentieth century manifestations.

Psychodynamic psychotherapies: Evidence-based practice and clinical wisdom

This article is based on an exhaustive review of the psychotherapy outcomes literature, undertaken originally at the instigation of the UK Department of Health by Roth and Fonagy (Department of Health, 1995). We have recently updated this review (Fonagy, Target, Cottrell, Phillips, & Kurtz, 2002; Roth & Fonagy, 2004) and extended it to identify all studies of psychoanalytic psychotherapy. The usual methods for identifying studies were employed (Fonagy, Target, et al., 2002; Roth & Fonagy, in press). The key questions that should be asked of this literature given the current state of research in this area (also see Westen, Morrison, & Thompson-Brenner, 2004) are: Are there any disorders for which short-term psychodynamic psychotherapy (STPP) can be considered evidence-based, Are there any disorders for which STPP is uniquely effective as either the only evidence-based treatment or as a treatment that is more effective than alternatives, and Is there any evidence base for long-term psychodynamic psychotherapy (LTPP) either in terms of achieving effects not normally associated with short-term treatment or addressing problems that have not been addressed by STPP? In this context, short-term therapy is conceived of as a treatment of around 20 sessions delivered usually once weekly.

What converges and what diverges when religious object representations transform? An annotated critique of Cohen (2002)

This essay is a discussion of several elements of Mariam Cohen's (2002) psychoanalytic reflections regarding the autobiographical account of Judith Bruder's gradual religious conversion from Orthodox Judaism to Catholicism. Despite advances in theory, it remains unclear how psychoanalysis is to accommodate the notion of an objective divine entity that truly exists behind the patient's religious representations. It would seem that the particular kind of object posited by religion is destined to remain the insoluble and nonnegotiable limit of psychoanalysis, akin to the virtual "navel" that Freud hypothesized as the endpoint or foveal spot of every dream. In order to advance theory and practice, the material used for discussion must be the product of some kind of intensive psychoanalytic process. Practically, it seems inaccurate, or at least incomplete, simply to state that a religious personality or representation has "converged into integration," as Cohen emphasizes, without also acknowledging that salient divergences occur simultaneously, whose tandem cooperation with convergence signifies healthy mindedness.

The effect of stress on menstrual function

Historically difficult to define, stress is, in one sense, the factor that stressors have in common in their impact on the body. Menstrual function is disrupted by stressors that activate the hypothalamic-pituitary-adrenal (HPA) axis; this activation is part of a catabolic response of the whole body that mobilizes metabolic fuels to meet energy demand. Functional menstrual disorders are associated with an increase in cortisol and with a broad spectrum of other symptoms of energy deficiency. Recent experiments suggest that exercise and other stressors have no disruptive effect on reproductive function beyond the impact of their energy cost on energy availability. These studies suggest that treatments for functional menstrual disorders should aim at dietary reform and that stress is simply low energy availability. Future experiments should carefully test this hypothesis.

Comorbid depression and anxiety in fibromyalgia syndrome: relationship to somatic and psychosocial variables

OBJECTIVE

The prevalence as well as predictors of psychiatric disorders (Diagnostic and Statistical Manual of Mental Disorders, 4th edition [DSM-IV] axis I and II) in patients with fibromyalgia syndrome (FMS) was evaluated.

METHOD

One-hundred fifteen patients with FMS participated in the Structured Clinical Interview for DSM-IV to assess current mental disorders. In addition, patients completed standardized questionnaires regarding pain, pain impact, anxiety, depression, posttraumatic stress disorder-like symptoms, and sexual and physical abuse.

RESULTS

Patients were grouped into one of three psychosocial subgroups based on responses to the Multidimensional Pain Inventory (MPI)-Dysfunctional (DYS), Interpersonally Distressed (ID), and Adaptive Copers (AC). Axis I diagnoses were present in 74.8% of the participants overall with the DYS subgroup mainly reporting anxiety and the ID group mood disorders. The AC group showed little comorbidity. Axis II diagnoses were present in only 8.7% of the FMS sample.

CONCLUSION

These results suggest that FMS is not a homogeneous diagnosis, but shows varying proportions of comorbid anxiety and depression dependent on psychosocial characteristics of the patients. The results demonstrate the importance of not treating patients with FMS as a homogeneous group. Assessment should not only examine the presence of widespread pain and the number of tender points, but also the presence of affective distress. Treatment should focus both on physical and emotional dysfunction.

A falsifying adolescent

The author describes an adolescent patient who, while often speaking factual truths, maintained an aura of falsity in her life, and in two interludes of psychoanalytic psychotherapy, that functioned as a barrier to psychological insight. To match her falsity, the analyst at times modified his functioning as a "real" therapist and took on her personification of neglectful and false adults. Eventually, the analyst became an object that the adolescent could trust and rely on. In discussing the case, the author introduces and applies Bion's ideas regarding truth and falsity, and three variations of container-contained relationships-symbiotic, commensal, and parasitic-in the context of the case's relational perspective.

Disorganized attachment and borderline personality disorder: a clinical perspective

The aim of this paper is to explore the links between the attachment-theory derived concept of disorganized attachment, and the psychiatric diagnosis of Borderline Personality Disorder (BPD). Disorganized attachment can be understood in terms of an approach-avoidance dilemma for infants for whom stressed or traumatized/traumatizing caregivers are simultaneously a source of threat and a secure base. Interpersonal relationships in BPD including those with care givers is similarly seen in terms of approach-avoidance dilemmas, which manifests themselves in disturbed transference/countertransference interactions between therapists and BPD sufferers. Possible ways of handling these phenomena are suggested, based on notion of 'meta-cognitive monitoring', in the hope of re-instating meaning and more stable self-structures, in these patients' lives.

Despair: a unitary appreciative inquiry

A unitary appreciative case study method was used to explicate unitary understandings of despair embedded in the unique personal life contexts of the participants. Fourteen women engaged in dialogical, appreciative interviews that led to the creation of profiles of the life pattern or course associated with despair for each woman. Three exemplar cases are detailed including the profiles that incorporate story, metaphor, music, and imagery. The voices of the women provide morphogenic knowledge of the contexts, nature, consequences, and contributions of despair as well as practical guidance for healthcare providers.

Childhood trauma and adult interpersonal functioning: a study using the Core Conflictual Relationship Theme Method (CCRT)

OBJECTIVE

This study aimed to examine the long-term correlates of childhood trauma in regard to interpersonal functioning in adulthood.

METHOD

One hundred and nineteen (N=119) subjects from the Austen Riggs Follow-along Study were included in the study. The Traumatic Antecedent Interview scoring method was used to assess 10 types of childhood trauma. Two additional positive variables were also assessed. Interpersonal patterns in adulthood were assessed using the Core Conflictual Relationship Theme Method.

RESULTS

Subjects reporting childhood physical abuse had a higher prevalence of the wish to be hurt, and experienced others as strict and stern. Those reporting physical neglect had a higher prevalence of the need to be comforted. Subjects who had experienced significant separations during childhood later felt less self-confident in interpersonal situations. Results also showed that subjects who had access to a caretaker/confidant had less need for love. A number of additional findings were nominally significant but did not remain so after correction for multiple comparisons.

CONCLUSIONS

The findings indicate that internalized thoughts and affects regarding childhood traumatic events may still play a role long after the time period of the events. Results also suggest that a continuous measurement approach to the study of traumata may provide information not captured by a dichotomous approach.

The place of erotic transference and countertransference in clinical practice

Patients who express intense, erotic attraction to their therapists pose special treatment challenges that may not respond well to the interpretative effects of the therapist. The wish that the therapist demonstrate love for the patient and the therapists' own erotic feelings toward such patients can create misalliances as well difficult technical moments. Furthermore, some patients expressing their love for their therapist may have physiological manifestations while others would not. At the same time, therapists may not experience erotic feelings toward the patients' expressions of love. The purpose of this paper is to try to answer the following questions: How do we conceptualize our patients' erotic manifestations? Are those expressions of Oedipal or preoedipal pathology? What are the countertransference reactions of the analyst? Two clinical examples will highlight these issues.

Repetition Compulsion in a Trauma Victim: Is the “Analgesia Principle” Beyond the Pleasure Principle? Clinical Implications

This paper reviews the concept of repetition compulsion (RC) from Freud's original formulation to recent contributions from psychoanalysis and the neurosciences. Literature on RC presented four major controversies: (1) Does RC describe a broad range of dysfunctional repetitive behaviors, or only the repetition of severe traumatic experiences? (2) Is RC an attempt to achieve mastery and control of a traumatic experience, or to reach a particular psychic state as analgesia or excitement, which reduces the perception of emotional pain? (3) Is the death instinct an acceptable explanation for RC? (4) Is RC a useful, meaningful, and specific concept? The author describes his personal perspective on RC which integrates psychodynamic and biological contributions. Clinical material is provided.