Dynamic Systems and the Therapeutic Action of the Analyst: II. Clinical Application and Illustrations.

The author presents a dynamic systems approach to psychoanalytic practice. It depicts psychoanalysis as an activity-dependent, experientially based treatment in which the analyst's behavior toward a patient effects change in how the patient organizes and interprets self-experience and relates to others. The neurobiological and relational components of this approach are reviewed, and their implications for psychoanalytic process and technique are described. Several clinical vignettes illustrate the technical application, dynamic process, and therapeutic action of a dynamic systems perspective on psychoanalytic treatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Ulcerative colitis: from medical management to ileal pouch anal anastomosis: a patient's perspective

Ulcerative colitis (UC) is a chronic disease that may require extensive medical and, at times, surgical intervention. Patients with UC are encouraged to form a multidisciplinary healthcare team to provide the support needed to cope with this chronic, debilitating illness. In this article, the authors provide the personal perspective of a patient coping with UC, the role of the gastroenterology nurse, and the viewpoints of key members of the healthcare team. Tracing the course of the disease from onset to medical management and then surgery, the authors relate the process by which the patient interacted with the healthcare team to reach the decision for seeking a surgical solution to the disease and how the patient coped with the rare but extended complications of surgery. The patient's decision illustrates the importance of her perspective and the varying roles played by the healthcare team. Medical management of UC and the technical aspects of ileal pouch anal anastomosis surgery are discussed.     

Countertransference as the analyst's experience of the analysand: Influence of listening perspectives.

Discusses countertransference as part of the analyst's larger experience of the patient, to capture the complexity of the analyst's involvement and correctly place it as a central guide for inquiry and interventions. The analyst's experience of the patient is shaped not only by the patient, but also by his listening perspective, models, and subjectivities. The analyst experientially can resonate with the patient's affect and experience from within the viewpoint of the patient (subject centered), or of the other person in a relationship with the patient (other centered). The analyst's listening from within and without, oscillating in a background–foreground configuration, can illuminate more fully the patient's experience of self and of self in relation to others. Case studies of 2 women and 1 man are included. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Meaning vs. medical necessity: Can psychoanalytic treatments exist in a managed care world?

With more and more insured employees covered by behavioral managed-care organizations (MCOs), psychoanalytically oriented practitioners are confronted with the dilemma of trying to deliver meaning-based treatments in a medical-necessity setting. Like many psychoanalytic dilemmas, resolution requires an appreciation of the situation from the perspective of the other, that is, understanding health care from the perspective of the employer. On the basis of his experiences as a case manager, the author specifically suggests the importance of understanding (1) that the medical necessity standard requires distinguishing health care from growth experiences; (2) population as well as patient needs; (3) four reasons why psychoanalytically oriented clinicians are not popular with payers and vice versa. Supported by vignettes, clinical experiences, and literature, some specific recommendations are presented for analytic clinicians which might allow for less frustrating interactions with the healthcare system. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The cytomorphologic features of sclerosing mucoepidermoid carcinoma of the thyroid gland with eosinophilia

The computer-based patient record (CPR) is a tool likely to have great impact on the practice of medicine in the years to come. Yet, clinical settings with a fully integrated CPR are hard to find. This paper takes a sociological look at the attempts to construe and introduce CPRs. It is argued that part of the current trouble in getting these tools to work lies in the model of medical work that is inscribed in many (attempted) CPRs. A more sociological perspective on medical work should be able to offer points of departure for the construction of systems which might fit the needs of health care workers better. Based on participatory observation, the paper outlines what it is medical work comes down to from a sociological perspective, and how the medical record figures in this work. Finally, some consequences this depiction has for current discussions on and (proposed) implementations of CPRs are described.     

A multivariate analysis of the early dropout process.

Performed principal-component factor analyses on patient input (demographic and pretherapy expectations), therapist input (demographic), and patient perspective therapy process variables that significantly differentiated 71 early dropout from 110 nondropout outpatients at 2 community mental health centers. At 1 setting results confirm (a) the presence of selection factors in the intake process whereby the more disturbed patients, who subsequently drop out, are assigned to lower level trained therapists and (b) the proposition that many patients unilaterally terminate despite the perception of the initial session as being an overall positive experience. Findings at the 2nd setting support the more traditionally held view of "dropout" as related to patient dissatisfaction with received services. Differences in the dropout process at the 2 settings were attributed to empirically demonstrated differences in the therapists' theoretical approach to the initial interview. The proclivity of earlier investigators to conceptualize dropouts as being characteristic of a single type of patient seems to be another unfounded homogeneity myth. (22 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Cost-effectiveness of open versus laparoscopic repair for primary inguinal hernia

A cost-effectiveness (CE) analysis was performed of Bassini versus laparoscopic repair for primary inguinal hernia. Incremental costs per 1-year recurrence-free patient were calculated for the societal and hospital perspective. From the hospital perspective, the incremental CE ratio of laparoscopic repair is 5.348 guilders. From the societal perspective, laparoscopic repair is both less costly and more effective than Bassini repair. Results were sensitive to assumptions about recurrence rates, laparoscopic operating time, and return to work. Laparoscopic repair should replace Bassini repair in order to benefit society. From the hospital perspective, the decision to accept laparoscopic repair depends on the willingness to pay.     

Value decisions in therapeutically-induced acute psychotic episodes.

A serious value conflict occurs when psychotherapy precipitates an acute psychotic episode in a patient. Two perspectives are proposed: According to the 1st, such situations are to be avoided because the therapist is endangering professional responsibility and accountability for the patient's welfare. According to the 2nd perspective, the immediate value-laden fears of the therapist are conceptualized as grist for the therapeutic mill, and 5 ways are proposed to use these fears to carry forward the therapeutic process and to deal constructively with the psychotic episode and the therapist's value-laden fears. (19 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Patient perspective of long-term outcome of augmentation cystoplasty for neurogenic bladder

OBJECTIVES: Although the urologic outcomes of augmentation cystoplasty for neurogenic bladder dysfunction are well known, additional information about the patient perspective is needed. The aim of this study was to assess patient perspective using a standardized questionnaire. METHODS: Fifty-nine patients, who had undergone augmentation enterocystoplasty as part of reconstruction mainly to correct hyperactive bladders and incontinence, were subjected to a questionnaire after a median of 76.1 postoperative months. The questionnaire addressed medications, catheterization, incontinence, bowel dysfunction, and satisfaction with urinary tract management. The urologic outcomes regarding upper and lower tract changes, complications, and reinterventions were documented as well. RESULTS: The patients experienced a significant increase in bladder capacity and decrease in pressure at capacity (P < 0.0001). Normal upper tracts remained normal and there was either improvement or stabilization of hydronephrosis. Twenty-four patients (40.6%) had one or more complications, with 21 requiring reinterventions. Twenty-five percent of patients required the reintervention within the first 25 months, and the median time to reintervention was almost 10 years. Thirty-five patients took medications such as anticholinergics, antidiarrheals, or antibiotics. Fifty-six patients were treated with clean intermittent catheterization (CIC) at a mean interval of 4.6 hours. Seven patients had some difficulty with CIC. Thirty-nine patients (67%) were dry, and 17 had mild and 3 severe incontinence. Eleven patients (18.6%) reported bowel dysfunction, although 7 had it preoperatively. Almost all patients were very satisfied with their urologic management. CONCLUSIONS: The high degree of patient satisfaction attests to the value of the procedure. The complication and reintervention rates underscore the importance of long-term follow-up.     

The Capgras syndrome: Neurological/neuropsychological perspectives.

Discusses the Capgras syndrome, a disorder in which the patient believes that a close friend, relative, or other person is not the real person but an exact look-alike or impostor. References in the literature are reviewed regarding a neurological/neuropsychological cause of the disorder. The focus is shifted from a psychodynamic approach to a wider perspective, conceptualizing the syndrome as a disorder of the central nervous system (CNS). The importance of considering neurology and neuropsychology in proper diagnosis and treatment is highlighted. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

How patients coach their therapists in psychotherapy.

Examines coaching behavior in the therapeutic relationship from the perspective of control mastery theory. The expanded concept of coaching presented here views the patient as actively engaged throughout therapy in prompting, instructing, and educating the therapist to relevant aspects of the patient's plan for disconfirming pathogenic beliefs and attaining treatment goals. Three therapy situations encountered when coaching is prominent are identified and illustrated with clinical vignettes. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Leaving chastity behind: The analyst's use of her sexual response.

The analyst's sexual subjectivity is not only a source of vital information to be distilled privately but also the wellspring for effecting change, especially in those patients who see in their sexual selves essential aspects of their being. To engage these aspects of the patient, this article argues that the female analyst must also allow her own erotic response, including attendant emotions, to become available for discourse with the patient. Clinical illustrations provide a perspective from a female clinician in a primarily heterosexual position with male patients. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Review of Freud's case studies--Self-psychological perspectives.

Reviews the book, Freud's case studies--Self-psychological perspectives edited by Barry Magid (see record 1993-97398-000). The authors of the chapters demonstrate varying capacities to understand that all understanding is theory bound. The result is that some lean toward the position that self psychology offers us the true perspective through which we can understand a patient, whereas Freud was woefully lacking in any interest in immersing himself in the subjective experience of the patient. Empathy is seen by some authors as the exclusive domain of the self psychologists. By the end of this fascinating volume, one is newly excited by the depth psychology revealed via Freud's discoveries and by the possibilities of a continuing legacy of discovery. Familiar patients are revealed in new ways, giving evidence of the evolving nature of this complex science. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Cupid's misses: Relational vicissitudes in the analyses of single women.

Addresses the interface between adult needs for intimacy and the psychoanalytic process between a certain population of single female patients and their male analysts. Relational vicissitudes of this patient–analyst pairing are discussed from a perspective that is both psychoanalytic and psychosocial. Influences of gender differences, sociological factors, and the existential nature of prolonged unchosen singlehood on the female analysand's subjective experience are discussed. This discussion is followed by an exploration of the ramifications of singlehood for the analytic process and for the analytic relationship. The concepts of primary intimacy and a primary relational void are introduced, and clinical illustrations are incorporated. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The benefits and risks of patient self-disclosure in the psychotherapy of women with a history of childhood sexual abuse.

This article explores the potential benefits and risks of patient self-disclosure in the psychotherapy of adult women survivors of childhood sexual abuse (CSA). Two primary questions frame this discussion: How are the primary benefits of patient disclosure influenced by CSA status, and what are the specific risks associated with each of these benefits in the case of CSA patients? The authors examine these questions by evaluating, from the perspective of clinical work with CSA patients, each of 6 putative benefits of self-disclosure in psychotherapy: self-awareness and identity formation, intimacy, validation and affirmation, differentiation, authenticity, and catharsis. The authors suggest that although clinical work with CSA survivors often necessitates encouraging these patients to discuss traumatic material, such disclosure may include substantial costs as well as benefits. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Patient variable biases in clinical judgment: Conceptual overview and methodological considerations.

Specific conceptual factors are presented as having contributed to the negative findings of past psychotherapy bias research. Among these factors are the restrictive nature of both the definition of bias and the model of the biased clinician. A review of published studies of several patient variable biases (e.g., gender, race/ethnicity, and age) indicates that bias may best be defined in broader terms and that its occurrence may be more circumscribed than originally conceived. In addition, the lack of a theoretical perspective in this area of research is noted and the applicability of some social cognitive processes is discussed. Methodological factors are also considered, and recommendations for future research are offered. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

On objects, transference, and two-person psychology: A critique of the new seduction theory.

Object relations theory (ORT) has become the dominant theoretical perspective in the psychoanalytic realm. However, weaknesses in the object relations perspective have not been examined sufficiently. In particular, the frequent lack of clarity as to whether a given reference to an object refers to an internal representation or an external figure has resulted in problems, distortions, or misapplications in the clinical utilization of ORT. This lack of clarity has the effect of transferring the therapist's attention to the role of the external world at the expense of attending to the internal world and structure of the patient. This shift to the external interpersonal world has particular implications for models of transference and therapeutic intervention. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A legal and ethical review of patient responsibilities and psychotherapist duties.

The ethics and standards of practice literature has long focused on the duties that psychotherapists owe their patients. While this has been valuable to the profession, it has created a circumstance in which psychotherapists have focused on their duties and responsibilities to their patients with little understanding or respect for how the conduct of a patient can impact those factors. These articles will review these factors from both an ethical and legal perspective. In addition, all of the articles discuss the premise that, while the psychotherapist has the primary responsibilities when rendering treatment to a patient, the treatment alliance is actually a dynamic that changes depending upon the conduct of both the psychotherapist and the patient. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Attribution and expressed emotion in the relatives of patients with schizophrenia.

[Correction Notice: An erratum for this article was reported in Vol 101(2) of Journal of Abnormal Psychology (see record 2008-10481-001). An incorrect sentence was published. The sentence that ends the fourth paragraph on p. 547 ought to read: A more recent onset of illness would be expected to produce more unstable attributions, and more disturbed behavior (particularly involving violence toward the relative) would be expected to produce attributions that were more internal and personal to the patient but more external and uncontrollable as regards the relative.] Indexes of expressed emotion (EE) in 58 relatives of patients with schizophrenia were related to those relatives' spontaneously expressed causal beliefs about the illness and about related symptoms and behaviors. Relatives made attributions predominantly to factors external, universal, and uncontrollable from their own perspective, and to factors internal, universal, and uncontrollable from the patient's perspective. Low-EE relatives were similar in their attributions to emotionally overinvolved relatives. Compared with these 2 groups, critical and/or hostile relatives made more attributions to factors personal to and controllable by the patient. Subsequent analyses suggested that hostile relatives were further characterized by making more attributions to factors internal to the patient and by making attributions with fewer causal elements. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

An empirical approach to studying psychoanalytic process.

This study was a pilot attempt to investigate psychoanalytic process from an empirical perspective. We randomly selected early and late sessions from an audiotaped psychoanalysis (N = 324 sessions) and scored them using a modified form of the Gill-Hoffman (1982) system. We analyzed these scores via Markov models and comparative probability tests. The coding scheme was reliable, although the percentage of interrater agreement for ratings of patient insight was low. Despite this measurement error, the study yielded interesting findings concerning early and late hours. Across early and late sessions, interpretations facilitated patient transference insight, compared to other interventions within the same hours. The patient was somewhat more likely to follow one insight with a second during late hours. There were several other suggestions of longitudinal change toward greater patient mastery. We also explored the interrelationship between type of interpretation and patient productivity of transference insight. The findings indicated that the piloted method represents a useful way to pinpoint theoretically important interactions for empirical investigation. (PsycINFO Database Record (c) 2010 APA, all rights reserved)