The (Suicidal-) Depressive Position: A Scientifically Informed Reformulation

Integrative Psychotherapy With Physicians In the Trenches: Convergence of Cognitive, Existential, and Psychodynamic Processes

In this article, I present insights gleaned from over a decade of working in therapy with physicians in the trenches who practice at general hospitals located in an area afflicted by the community and political violence, and recently, by the COVID-19 pandemic. Psychotherapy with these physicians requires an integrative psychotherapeutic approach that heeds their changing needs. Espousing cognitive-existential psychodynamics (CEP), a theory-based psychotherapeutic perspective developed for complex cases, I show how cognitive, existential, and psychodynamic processes strongly converge during the treatment of physicians in the trenches. Such convergence is manifested in issues of mental representations (of death, medicine, and the hospital) and choice/meaning.

Reformulated Object Relations Theory: A Bridge Between Clinical Psychoanalysis, Psychotherapy Integration, and the Understanding and Treatment of Suicidal Depression

In contrast to the fruitful relationship between psychoanalysis/psychoanalysts and the humanities, institutionalized psychoanalysis has been largely resistant to the integration of psychoanalysis with other empirical branches of knowledge (infant observation, psychotherapy research, psychological and neurobiological sciences), as well as clinical ones [primarily cognitive-behavioral therapy (CBT)]. Drawing from two decades of theoretical and empirical work on psychopathology, psychotherapy, and psychoanalysis, the author aims to show how a reformulation of object relations theory (RORT) using (neuro-)psychological science may enhance a clinical-psychoanalytic understanding and treatment of suicidal depression, which constitutes one of the most formidable health challenges of our time. Specifically, he rewrote the notion of Melanie Klein positions-primarily the depressive position-using extant knowledge of structure of emotions, the centrality of mental representations of the future ("prospection") and the toxic nature of criticism-based emotions. This reformulation enables a dialog between clinical psychoanalysis and other therapeutic schools of thought and sheds light on the understanding and treatment of suicidal depression.

The Nature of the Beast: Commentary on “Can There Be a Recovery-Oriented Diagnostic Practice?”

Pavlo, Flanagam, Leither, and Davidson attempt to reconcile the recovery movement in mental health service with a formal diagnostic practice is as courageous as it is timely. Acknowledging this, I note several points of convergence and divergence with the authors’ views. Points of convergence include (1) the inevitability of a diagnostic system when working with (severe) mental illness, (2) the importance of going beyond signs and symptoms in capturing the unique characteristics of the person, (3) the focus on humanistic values, particularly the emphasis on a collaborative assessment and on human strengths, in the diagnostic process, and (4) the role of future-oriented thinking in diagnosis. Divergence with the authors concerns (1) my own reliance on descriptive psychiatry, with its focus on signs and symptoms, as a part and parcel of an effective diagnosis, (2) the potential benefits of psychological tests, for example, self-report questionnaires and projective procedures over and above the clinical interview, and (3) my emphasis on mental representations of self-with-others, termed here and elsewhere as “agents in relations,” as the building blocks of personality and psychopathology.

Steps Toward an Integrative Clinical Systems Psychology

Clinical fields of the "sciences of the mind" (psychotherapy, psychiatry, etc.) lack integrative conceptual frameworks that have explanatory power. Mainly descriptive-classificatory taxonomies like DSM dominate the field. New taxonomies such as Research Domain Criteria (RDoC) aim to collect scientific knowledge regarding "systems" for "processes" of the brain. These terms have a supradisciplinary" meaning if they are considered in context of Systems Science. This field emerges as a platform of theories like general systems theory, catastrophe theory, synergetics, chaos theory, etc. It provides a lot of abstract concepts, constructs, methods and models. We assume that these tools also enable theoretical integration in the diversified field of clinical practice in the sciences of the mind. Additionally, systems thinking in clinical psychology improves conceptual links to currently network-oriented neurobiology. However, clear definitions of systemic terms are necessary to emerge from their mainly metaphorical use. Here we revise mainly terms like "structure", "process" and "dynamics" as they are used already in psychology, psychoanalysis, psychopathology and psychiatry in an ill-defined way. For instance, affective-cognitive structures like "life space" or "object representations" can be seen as products of mental processing. These structures, in turn, modulate dynamics of mental processes. Additionally, we suggest a coupled network concept of emotions and motivations as the main subsystem that modulates mental dynamics that results in a qualitative systemic model of the mind. Finally, we assume that a revisited systemic approach could improve interdisciplinary understanding of the mental.