The advanced practice of psychotherapy

The advanced practice of psychotherapy involves deconstructing and transcending separate schools in the search for universal healing processes. Knowledge from major psychotherapeutic schools over the last 100 years, as well as ancient teachings over the last 5000 years, is distilled in the training and formation of the psychotherapist. Five major elements of training (theory, technique, the patient, the therapist, and the patient/therapist relationship), as well as one element in the therapist's formation (the person), are presented. To be a true healer, the clinician must cultivate his or her soul and spirit. Only then can the therapist guide the patient to reach his or her authentic self.

Spiritual psychotherapy

The author proposes the practice of spiritual psychotherapy, which transcends but does not preclude traditional modalities or strategies of treatment. The terms soul and spirit are distinguished as different transpersonal abstractions, yet are inextricably linked. The former aims at revealing the mystery of relatedness and intimacy in everyday life, the latter at finding the divine in universal life. For the spiritual therapist, these concepts are applied to a therapeutic context of care and compassion--which means love and belief beyond oneself. More specifically, the way to soulfulness requires Love of Others, Love of Work, and Love of Belonging, whereas the way to spirituality requires Belief in the Sacred, Belief in Unity, and Belief in Transformation. By cultivating a soulful and spiritual existence, thus conducting one's clinical practice on the basis of these six tenets of transcendence, the therapist can guide the patient to reach his or her own authentic self.

Notes on a contextual approach to medical ward consultation: the importance of social system mythology

The psychiatric consultant requires a broad understanding of the context of consultation to supplement his knowledge of psychodynamics. The authors propose viewing the medical ward in the model of a “quasi-open community,” in which a culture is transmitted from one generation of personnel to the next through a ward mythology-which embodies ideals, for example, for the roles of Nurse and Doctor. Requests for psychiatric consultation often result from the partial breakdown in this mythology; the consultant's immediate task is to reconstruct group ideals and facilitate community re-unification in order to promote the recovery of patients. Later on, when the staff has had a chance to distance itself from the threat to its solidarity, the consultant can help the ward community understand both the adaptive and non-adaptive aspects of its own mythology. Case examples illustrate how respecting the quasi-open character of the medical ward and giving credence to its mythology can promote the reconstitution of ward communities in disarray and aid individual patients as well.

Academic psychiatry and managed care: a case study

An academic department of psychiatry in New York City eliminated the need for behavioral managed care intermediaries by transforming itself from a fee-for-service system to a system able to engage in full-risk capitation contracts. The first step was to require health maintenance organizations to contract directly with the department. The department formed two legal entities, a behavioral management services organization for utilization management and a behavioral integrated provider association. The authors describe these entities and review the first year of operation, presenting data on enrollees, capitation rates, and service utilization for the first three contracts. The fundamental differences in the treatment model under managed care and under a fee-for-service system are highlighted. The authors conclude that by contracting directly with insurers on a full-risk capitation basis, departments of psychiatry will be better able to face the economic threats posed by the cost constraints inherent in managed care and maintain or re-establish their autonomy as care managers as well as high-quality care providers.

Gender differences in recalled parental childrearing behaviors and adult self-esteem

A retrospective questionnaire study investigated gender differences in the relations between the self-reported self-esteem of 155 psychiatric adult outpatients and their recalled experience of their parents' behavior toward them as children. There were no significant sex differences in degree of self-esteem. However, it had a higher correlation to parenting variables for the men than for the women, with maternal predictor variables accounting for 36% and paternal predictors accounting for 32% of the variance in the men's self-esteem. Neither combined maternal nor combined paternal variables were significant predictors for women. For men, parental acceptance/ autonomy was significantly and positively related and inconsistency negatively related to self-esteem. Paternal rejection but not maternal rejection was significantly associated with low self-esteem only for the women. The greater amount of variance explained by childrearing variables in the men's self-esteem scores was attributed to the earlier ego development and consequent increased individuation in women.

The psychological mindedness scale : factor structure and relationship to outcome of psychotherapy

Two studies are reported. The first examined the factor structure of the Psychological Mindedness (PM) Scale, and the second reassessed the scale's predictive validity. A principal components analysis (varimax rotation) of the data of 256 psychiatric outpatients produced five factors that accounted for 38% of the variance. A tentative definition of PM based on these factors is proposed. For a subsample of 116 patients who attended at least four psychotherapy sessions, PM was unrelated to levels of functioning and psychosocial symptoms at admission and was positively associated with number of sessions attended, consistent with findings of a preliminary investigation. Not replicated were significant correlations between PM and outcome measures derived from therapists' and an independent rater's evaluations. Initially high PM was significantly related to patients' self-ratings of symptoms and problems after discharge.

Transtheoretical practice of psychotherapy

A developmental model forms the framework for the transtheoretical practice of psychotherapy. Major preoedipal and oedipal events, interfaced with significant two-person (mother-child) and three-person (father-mother-child) influences--dyadic deficit, dyadic conflict, triadic deficit, triadic conflict--are instrumental in the formation of different relationship patterns in treatment that transcend classical versus selfobject transferences. Therapeutic as well as countertherapeutic stances and strategies are elucidated.

Relationships between psychological mindedness and personality traits and ego functioning: validity studies

Two studies further investigated the psychometric properties of the self-report Psychological Mindedness Scale (PMS), which has been shown to have good internal consistency and evidence of predictive and divergent validity. Its construct validity was investigated by assessing (1) whether total scores on the PMS of a group of medical students attending a personnel clinic in a psychiatric outpatient setting would be related in theoretically expected ways to their scores on a personality test; and (2) whether total scores on the PMS of a group of regular clinic patients would have the expected theoretical relationships to scores on a measure of ego functions. The findings of both studies provided support for the construct validity of the PMS.

Determinants of outpatients' satisfaction with therapists : relation to outcome

This study investigated outpatients' satisfaction with therapists, as determined by their perceptions of therapists' behaviors and characteristics, and related patient satisfaction to measures of psychotherapy outcome derived from patients themselves, therapists, and an independent rater. After discharge, 138 demographically and diagnostically heterogeneous patients who had been in psychodynamically oriented psychotherapy returned mailed questionnaires. Therapist characteristics and behaviors such as being likeable, accepting, encouraging, and respectful, helping patients to understand themselves better, and not being "too quiet," as well as overall ratings of satisfaction with therapists, were significantly correlated with patients' ratings of improvement and of help received and with therapists' ratings of outcome.

A developmental metatheory of psychopathology

The author proposes an integrative model of psychopathology in light of the contemporary need to bridge diverse ideological frameworks. This model has its major foundations in drive, ego, object relations, and self psychoanalytic perspectives as they impact upon interactional patterns of infancy. The chronology of these theoretical orientations is presented as parallel to a changing focus upon different successive stages in the course of individual development. The longstanding controversy between conflict and deficit theories, which undergirds the various schools of thought, is addressed: a developmental orientation is offered as the overriding conceptual connection between them. Conflict and deficit phenomena are regarded as intertwined and not incompatible: Unconscious drives, desires and wishes, ego defenses, and compromise formations as well as object relationship deficiencies and structural voids and defects in the self are combined to encompass a broad spectrum of psychopathology and its sources: the above intrapsychic and interpersonal factors are interfaced with significant reciprocal dyadic (mother/child) and triadic (father/mother/child) influences upon ongoing maturational processes. For heuristic purposes, a fourfold matrix--dyadic deficit, dyadic conflict, triadic deficit, and triadic conflict--is delineated. Clinical characteristics and developmental precursors of each of the four prototypes, especially with regard to early relational events, are examined.

Strategies of therapist interventions : a preliminary empirical study

Forty-one categories of patient communications just before therapist interventions were identified from a review of psychotherapy transcripts. For each communication type, a set of possible therapist interventions was constructed. Descriptions of these interactions were sent in the form of a questionnaire to 350 experienced clinicians, who were asked to indicate their degree of agreement with each possible response. Ratings from the 141 responding clinicians showed little relation to age, gender, experience level, or orientation but showed marked differences for different response alternatives. A separate group of seven experienced clinicians used these data to develop a new categorization of 15 types of therapist interventions and 5 types of patient communications. A tentative information-processing model of patient-therapist communications is proposed.

Critical incidents in psychotherapy

The critical-incident technique was used to obtain a list of patient behaviors that create special difficulties for the psychotherapist. The list was prepared by a group of seven clinicians during a series of meetings. Included in the list were such items as: insulting the therapist; coming late to the session; threatening suicide; and offering gifts. The list was given to 21 experienced psychiatrists who were asked to rate both the importance and the frequency of occurrence of each incident in their experience. The critical incidents could be divided into five major categories: threat of harm from the patient; criticism of the therapist or the therapy; occurrence of a major life crisis; attempts by the patient to seek friendship or seduction, and miscellaneous incidents, such as being consistently late. When ratings by the experienced psychiatrists were compared with those of 10 third-year psychiatric residents, it was found that the inexperienced psychiatrists in almost every case rated the incident as less important and more frequent than did the experienced clinicians. In terms of implications, knowledge of critical incidents in psychotherapy may provide a source of material for training purposes, may enable the development of modeling procedures for training in communication skills, and may encourage supervisors to focus attention on important therapeutic issues.

Development of a therapist activity rating scale: preliminary findings

A 61-item scale was constructed of relatively explicit descriptions of behavior in which a psychotherapist might engage. The scale is largely noninferential, is basically atheoretical but applicable to psychodynamically oriented therapy, may be completed by either the therapist or an independent rater with minimal training, and may be used to rate entire therapy sessions or specific segments of sessions. The scale shows high interrater reliability and discriminant validity.

A review of treatment studies of minor depression: 1980-1991

This article provides a brief overview of the changing nature of the concept of minor depression. It then discusses treatment studies conducted from 1980 to 1991 of patients diagnosed as neurotic depression, depressive neurosis or dysthymia, characterologic depression, "double depression" and minor depression or dysthymia, if there has been a full remission of a major depressive episode lasting at least six months prior to the development of dysthymia. Long-term treatment of chronic depression is also reviewed. Cognitive-behavioral intervention and marital therapy have been reported beneficial for patients diagnosed as having neurotic depression, characterological depression, or dysthymia. All studies of antidepressant drug treatment showed drugs to be efficacious and superior to placebo, with few differences found between drugs. In addition, they all showed the importance of analyzing the interactions between treatment and severity or diagnosis. Patients diagnosed as "double depression" also appear responsive to both psychosocial intervention and drug treatment; in general, however, these patients tend to have a poor long-term outcome and continued treatment is indicated. The most obvious finding to emerge from this review is that the diagnosis of minor depression is ambiguous, in large part because of the lack of defining criteria related to severity and course. The review also revealed that in addition to poorly defined subgroups, many studies lacked controls, had small sample sizes, inadequate and/or inconsistent measures of outcome, and limited follow-up. For these reasons, their findings cannot be considered conclusive. Finally, the literature revealed a dearth of controlled studies of psychosocial treatment for well defined subgroups of neurotic depression.

The worst of times, the best of times : psychotherapy in the 1990s

The author discusses the state of the art of psychotherapy at the brink of the new decade. The theme of the 1990s is rapprochement, the bridging of divisive aspects of the field. Four major manifestations of increased detente are explored: convergence of mind and brain, collaboration of research and public policy, coordination of economic constraints and ethical standards, and connection between psychopathology and therapeutic practice. Factors of major importance for the future of psychotherapy are the impact of the neurosciences on psychological phenomena, the role of the computer in human simulation, the socioeconomic influence of government and third-party payers on the direction of treatment, and the utilization of clinical practice in devising new diagnostic dimensions.

Developmentalist metatheory of depression and psychotherapy

Examination of the theoretical and clinical literature reveals that the psychological understanding of depression is complex and varied, often differing among major schools or theorists. These variations in conceptual perspective (e.g., drive, ego, object relations, self, interpersonal, cognitive) also naturally impact, directly or indirectly, upon the nature of treatment. This paper has attempted to integrate diverse points of view by offering a developmentalist metatheory based on the psychosexual maturation of the patient. More specifically, four basic prototypes of depression have been depicted: Dyadic deficit depression (DDD), dyadic conflict depression (DCD), triadic deficit depression (TDD), and triadic conflict depression (TCD). Each etiologically relates to early childhood experiences of the individual and is traced to different developmental periods with their own unresolved conflicts or deficient parent(s)/child scenarios. Clinical signs and symptoms as well as therapist/patient interactions have been described and respective technical measures recommended. This schema has therapeutic implications both for the reapproachement of multiple frameworks and for individualized practice in the treatment of depression.

Can personality traits predict psychotherapy outcome?

Ninety-six new admissions to a psychiatric outpatient clinic who attended a median of 14 therapy sessions completed a self-report Personality Profile Index prior to their first session. This index provides scores on eight dimensions of personality, a conflict measure, and a measure of social desirability. Scores were correlated with number of sessions and outcome as measured by a Symptom Checklist and by a Global Assessment Scale (GAS). Improvement was significantly related to number of sessions attended. Patients scoring high on being rejecting of others (rejection) were significantly less likely to show improvement after therapy. Rejection, aggression, passivity, and conflict were significantly related to the extent of symptoms and problems with which patients presented at the clinic.

Interrelations between ego functions and personality traits: their relation to psychotherapy outcome

Ninety consecutive admissions to a large outpatient clinic of a municipal hospital completed two self-report questionnaires: the Self-Evaluation Questionnaire (SEQ) which consists of four 10-item scales that assessed four areas of ego functioning; and the 89-item Personality Profile Index (PPI) that provided measures of eight dimensions of personality traits and also a measure of conflict. Results indicated that the four measures of ego functioning had good internal consistency, and three of the four ego functions had a highly similar pattern of relations to the personality trait dimensions and to the conflict measure. It thus appears that each set of constructs amplifies and sheds light on the other. Two of the ego function measures were significant predictors of psychotherapy outcome. They correlated highly with one another and also with a third measure of ego functioning. This fact, together with the similarity of their correlations with the personality traits, suggests that these ego functions represent different aspects of an underlying construct that could be called Ego Strength. Therefore, combining the three ego functions into a 30-item Ego Strength measure could provide an even more sensitive predictor of therapy outcome and a useful new instrument for psychotherapy research.

Psychological mindedness as a predictor of psychotherapy outcome: a preliminary report

This study investigated the properties of a new measure of psychological mindness (PM). A 45-item self-report questionnaire was administered to consecutive admissions to a large outpatient clinic that provides primarily psychodynamically oriented individual psychotherapy. The PM scores of a sample of 44 of these patients who attended a median of 15 sessions were correlated with several outcome measures obtained from retrospective chart reviews. These measures consisted of the number of sessions attended, discharge ratings, and change scores on a Global Assessment Scale (GAS) and on a symptom checklist. Coefficient alpha for the Psychological Mindedness (PM) Scale indicated high reliability. Total PM score correlated significantly with three of the outcome measures. Twenty of the 45-items were good predictors of one or more outcome measures.

[Psychotherapy in patients with obsessive-compulsive disorder]

The present paper is a study of the role of psychotherapy in the treatment of obsessive-compulsive disorders (OCD). It also includes an attempt to integrate several paradigms in order to obtain the best possible approach in helping each patient on an individual basis. The aim of this psychotherapy may limit itself to simple verifications in the pharmacotherapeutic follow-up, or it may be as ambitious as an attempt to modify the character structure of the individual. In the process of the latter case, one expects the defensive aim of symptoms to be no longer relevant, insofar as the patient successfully solves the conflicts that caused the symptoms. We can only use tags or labels to bear witness of the efficiency of such ambitious use of psychotherapy, and even these tags or labels seem to be concerned with compulsive personality rather than with OCD proper. At each end of the range of aims (encouraging the follow-up of pharmacotherapeutic or behavioral treatments vs character modification), the therapist is inevitably confronted with a multitude of features frequently present in the obsessive patient. Because it is a disorder which invades and influences the patient's feelings, thoughts, behavior and relationships with other people, the obsessive patient's mind is a constant prey to special problems at every meeting with his therapist, whether they be related to the administration of drugs or to a behavioral therapy regime. Obviously, such problems will multiply if one initiates systematic psychotherapy in such patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Malpractice in psychotherapy: an overview

This paper gives a capsule review of the major issues on the subject of malpractice for individual practitioners of psychotherapy. It examines the elements necessary to support a malpractice claim and presents examples of cases in specific areas of liability. Historically, the field of psychotherapeutic malpractice was largely inactive. However, recent court rulings reveal that psychotherapists are no longer immune to malpractice suits. In decreasing order of the likelihood of the plantiffs being successful in their suits are cases involving the misuse of the therapeutic relationship, breach of confidentiality, and cases that involve prevention of harm to third parties and to patients themselves. Malpractice suits based on negligence in providing appropriate treatment are beginning to emerge and will probably increase in frequency as the efficacy of biological treatment is demonstrated. Available solutions to the problems of malpractice are discussed. It is suggested that in addition to the existing external sanctions, there is a need for consultation plus educational programs to enhance our ability to practice within the boundaries that the courts have set for us.

Toward a clinical model of psychotherapy for depression, II: An integrative and selective treatment approach

This is the second in a two-part series on psychotherapy for depression. Considering depression as a spectrum phenomenon, the author goes beyond manual-based diagnosis to suggest criteria for the use of psychodynamic, cognitive, or interpersonal psychotherapy, with or without pharmacotherapy. He proposes a clinical model that is both integrative and selective and recommends shifting and sharing different therapeutic perspectives in tailoring treatment to the depressed individual.

Development of a scale for the measurement of symptom change in an outpatient clinic

A brief 21-item symptom rating scale, the Psychiatric Outpatient Rating Scale (PORS), was developed for use in outpatient clinics. On the basis of its initial use with 86 patients, it was shown to have high internal and interjudge reliability and evidence of concurrent and construct validity. Scores on the PORS correlated significantly with the Global Assessment Scale and with the number of sessions of psychotherapy. For a subsample of 45 patients rated on the PORS at the beginning and termination of psychotherapy, seven symptoms revealed highly significant improvement. The PORS appears to be a potentially useful measure of change in outpatient clinics.

Toward a clinical model of psychotherapy for depression, I: Systematic comparison of three psychotherapies

In a two-part series, the author explores the current status of psychotherapy for depression. In part I, three predominant approaches to the psychological treatment of depressive disorders today--psychodynamic, cognitive, and interpersonal--are described and contrasted schematically. They are depicted as conceptually different but potentially complementary with regard to 1) basic characteristics, including theoretical orientation, major strategies, goals, and mechanisms of change, and 2) respective advantages and limitations. This clinical comparison forms the foundation of an integrative and selective model for the treatment of depression.

New frontiers in psychotherapy

The author examines new frontiers in psychotherapy from the perspective of four major movements in clinical psychiatry today: (1) the science of psychotherapy, (2) time-limited and tailored treatment, (3) governmental guidelines and public policy-making, and (4) conceptual and clinical rapprochement. Attempts to standardize psychotherapy are evidenced by more refined diagnostic and statistical instruments, operationalized training and treatment manuals, and use of the computer in human simulation. The second movement is manifested by innovative short-term therapies, particularly tailored to depressed populations. The third direction is more extrinsic as cost-effectiveness increasingly becomes the guiding criterion of mental health care. The final frontier reflects attempts to weld various polarities in the field, not only by drawing on a vast psychological armamentarium but by providing new neurobiologic models for complex "psychological" phenomena, from dreams to dependency.

Ethics in the practice of psychotherapy: a survey

One hundred and one psychotherapists responded to a survey designed to obtain data concerning beliefs about various ethical issues encountered in psychotherapy. Opinions about ethical standards in many areas were quite varied for the entire sample. Differences also emerged when therapists were compared in terms of orientation and years of experience.

Self-report measures as predictors of psychotherapy outcome

A retrospective clinical study using existing patient records investigated the predictive value of a number of variables. Eighty-three new admissions to a large outpatient clinic completed a battery of eight self-report questionnaires that have been shown to be reliable and have a measure of discriminant validity. The battery consisted of items tapping anxiety, depression, obsessive-compulsive symptoms, phobias, borderline personality disorder, and histrionic, obsessive-compulsive, and paranoid personality styles. Outcome of therapy, which was predominantly dynamically-oriented, was assessed by residual difference scores computed from pre- and posttherapy Global Assessment Scale (GAS) ratings. Only patients attending five or more sessions (N = 37) were considered in the analyses. Patients high on the Anxiety Scale pretherapy showed relatively greater improvement in functioning than those with low initial scores. Patients scoring high on the Histrionic, Paranoid, and Obsessive-Compulsive Personality Scales showed the least relative improvement.

The psychotherapies: benefits and limitations

The promises and challenges of the psychotherapies today are explored in the areas of treatment, training, diagnosis, research, and review. Benefits discussed include advances in the science and standardization of psychotherapy assessment and practice; improved research tools for establishing therapeutic efficacy; development of new clinical modalities, especially short-term techniques; cooperative efforts to combine and integrate diverse methods of treatment; establishment of ethical codes of conduct for the therapist; and the application of computerized evaluation and cost-containment procedures. At the same time, limitations reflect the various conceptual confusions, research inadequacies, identity crises, political pressures, and economic constraints of the field. Of particular concern is the current "age of accountability" which has placed cost-effectiveness at the pivot of public policy in mental health care.

The specificity versus nonspecificity dilemma: toward identifying therapeutic change agents

The author examines the specificity versus nonspecificity dilemma that characterizes the unresolved question of how psychotherapy works. He explores different meanings and arguments on both sides of the controversy and attempts to identify three therapeutic change agents that all schools of therapy share as the basis of their different techniques: affective experiencing, cognitive mastery, and behavioral regulation. The roles and functions of these agents are discussed with regard to their potential complementarity in clinical practice.

Combined psychotherapy and pharmacotherapy for depression. A systematic analysis of the evidence

To determine whether combined psychotherapy and pharmacotherapy is superior to alternative therapies for unipolar depression, we reviewed all controlled studies of outpatients treated for unipolar depression reported between 1974 and 1984. To accomplish this, we developed a new statistical approach that is specific in its method of evaluating the quality of each study and specific about the weights given to each outcome. The combined active treatments (drugs plus psychotherapy) were appreciably more effective than the placebo conditions but only slightly superior to psychotherapy alone, pharmacotherapy alone, or either of these combined with a placebo.

Psychodynamic variables as predictors of psychotherapy outcome

Predicting the outcome of psychotherapy is a central concern in psychiatry. Twenty-one medical students seeking psychotherapy were evaluated on a number of psychodynamic and process variables using self-report scales and scales completed by the therapist before, during, and after psychotherapy. There were significant differences between patients and a comparison group on eight variables before therapy. Ten psychodynamic variables (six representing ego defense mechanisms) and four process variables were found to be highly correlated with outcome measures; the process variables were the best predictors of outcome. The data support the use of psychodynamic and process variables as predictors of outcome in psychoanalytically oriented psychotherapy.

Recent developments in individual psychotherapy

Individual psychotherapy, the pivotal modality of psychiatry, has undergone a constant revolution since the inception of psychoanalysis; over the years the treatment models have shifted from dynamic to behavioral to experiential. The author discusses forces, such as economic pressures to establish cost-effectiveness, that have precipitated these changes. After reviewing comparative studies of the efficacy of psychotherapy, he examines new developments in individual psychotherapy such as brief treatment and cognitive therapy for depressive disorders. The efficacy of combined techniques, the impact of diagnostic tools and training manuals, and ethical issues, such as sexism, are also explored.

Learning dynamic psychotherapy: a longitudinal study

The authors investigated the evolution of psychotherapeutic skills over time in a group of psychiatric residents in their third year of training. A 29-item Supervisors Evaluation Scale measuring psychotherapy skills was developed. Each resident who began his or her clinical experience in conducting individual analytically oriented psychotherapy was rated by his or her supervisors on this scale toward the beginning of training and again 8 months later. Statistically significant changes were found for 7 of the skills measured. The authors feel that these may reflect those aspects of psychotherapy which the beginning therapist can readily learn with supervision and experience.

A suicide attempt by a seductive patient: what's the treatment plan?

For the past ten columns, we have been exploring questions of differential diagnosis and the ways to apply the Diagnostic and Statistical Manual of Mental Disorders, third edition, to the complexity of the clinical situation. We are now embarking on an even more uncharted and certainly more controversial area: differential therapeutics. In this column, to appear in alternate issues, we will learn how our guest experts would select treatment modalities for various clinical situations. We have the good fortune to lead off this new series with Toksoz B. Karasu, M.D., professor of psychiatry at Albert Einstein College of Medicine in the Bronx and director of psychiatry at the Bronx Municipal Medical Center, Dr. Karasu is the chairman of the American Psychiatric Association's commission on psychiatric therapies and has been deeply involved in studying how best to determine which treatments are most effective for which psychiatric disorders in which patients and circumstances.

Psychotherapy and pharmacotherapy: toward an integrative model

The author reviews historical trends, hypotheses, and problems in the application of pharmacotherapy and psychotherapy and uses research findings to develop an integrative model. He portrays a chronology of models over three decades; an "additive" relationship represents the decade of 1970 to 1980. He presents factors that must be considered in determining the effects of pharmacotherapy plus psychotherapy and recommends refinement of these variables in future research.

Psychotherapy with elderly patients

The purpose of this article is to present a review of the psychotherapy of the elderly, emphasizing traditional methods as well as some newer techniques. It will first review the literature on the process of psychotherapy in the elderly, then the rationale for such therapy will be discussed, and finally important technical points about such therapy will be listed, including information about the cognitive psychotherapies in the treatment of demented elderly.

Psychotherapy skill profiles of psychiatric residents

A survey of experienced clinicians has suggested that negative outcomes of psychotherapy may be related to misapplications or deficiencies of technique. The present study was, therefore, concerned with two questions: a) does the more competent psychiatric resident have a different profile of therapeutic skills from the less competent resident; and b) are the more competent residents more aware of their own behavior with patients than less competent residents? To answer these questions, a Supervisors' Evaluation Scale and a parallel Psychotherapy Self-Evaluation Scale were developed, and their reliability, content, and discriminant validities were established on the basis of their use with a group of psychiatric residents being supervised in an outpatient clinic. Results demonstrated that the more and less competent trainees, selected on the basis of global ratings, differed significantly on almost every item of the Supervisors' Evaluation Scale, but did not differ on most of the items of the Psychotherapy Self-Evaluation Scale. Residents reported it to be particularly difficult to deal with patients' aggression and acting out behavior, fee setting and collecting, and understanding the patients' defensive structures. The rating scales can be used to assist in supervision by assessing the level of acquired skills in psychotherapy, and can also be used to help identify special areas of strengths and weaknesses.

The ethics of psychotherapy

The author addresses the ethics of psychotherapy in terms of the interface between science and ethics, the goals of treatment, the therapeutic relationship, and special issues of confidentiality and therapist-patient sex. He considers the problems of multiple therapeutic modalities, dual allegiance of the therapist, the therapeutic use (and abuse) of power, and issues of dependency and suggests ways to maximize the clinician's exercise of ethical choices. Ethical dilemmas in psychotherapy are not entirely soluble; ultimately, the therapist, guided by his or her profession as a group, will be able to find answers to the complex problems that inevitably arise.