The management of sexualized transference and countertransference with older adult patients: Implications for practice.

For a variety of reasons, psychologists are beginning to see an increasing number of older adults in their practice. However, the sexualized transference and countertransference sometimes encountered with older adult patients can foster therapeutic impasse and resistance in treatment among both novice and experienced therapists. Societal taboos and therapy within the context of institutional settings (e.g., nursing homes) can make the management of these dynamics particularly challenging. Although difficult to broach, an analysis of sexualized dynamics can provide valuable information regarding an elderly patient's sense of intrinsic value, beliefs about power and agency, and difficulties with or desires for emotional intimacy. Case examples and implications for practice are presented. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The acceptability of a computer HIV/AIDS risk assessment to not-in-treatment drug users

The purpose of this paper is to report the results of a study assessing the acceptability of a computer HIV risk assessment instrument administered to not-in-treatment drug users. The study asked three questions related to acceptability: (1) are drug users comfortable responding to HIV risk questions using the computer assessment; (2) do drug users feel that they possess the requisite skill to respond to questions using a computer; and (3) do drug users believe that the responses they provide using the computer assessment will remain private and confidential. This study differs from other assessments of the acceptability of computer assisted data collection in that the population of interest has only limited education and interaction with computers. Furthermore, the study was implemented under field conditions. To conduct the study, an existing HIV risk assessment instrument was adapted for use with the computer. Only slight modifications were made to the content of the instrument. To facilitate data collection with this population, audio enhancement and touch screen were used. Three scales measuring comfort, skill and perceived privacy were developed. Results of analysis showed that drug users are comfortable responding to an HIV risk assessment using computer assisted interviewing. Drug users also perceived that they possessed the requisite skill to successfully complete the interview. And, study participants reported that they believed that their responses using the computer interview would remain private and confidential. Only minor differences in scale scores based on sociodemographic characteristics were found among study participants. Implications of the findings are discussed.     

Adverse reactions to trimethoprim-sulfamethoxazole among children with human immunodeficiency virus infection

BACKGROUND: The clinical course of HIV infection is frequently different among infants and children from that in adults. In adults among the most common sources of morbidity related to therapy are adverse drug reactions, notably to trimethoprim-sulfamethoxazole. Although there are case reports of serious adverse reactions to trimethoprim-sulfamethoxazole among infants and children with HIV infection, the precise rate and clinical characteristics of these adverse reactions among HIV-infected children are unknown. METHODS: We reviewed the clinical records of all children referred to a regional HIV clinic in a 6-year period. Therapy and suspected adverse drug reactions to therapy were reviewed by one of the investigators not involved in patient care. Adverse drug reactions were identified and characterized according to previously established criteria. RESULTS: During this time 78 children were referred for assessment of possible HIV infection, 45 of whom were ultimately determined to have the infection. Twenty-five were treated with trimethoprim-sulfamethoxazole, 15 (60%) of whom tolerated therapy and 10 (40%) of whom had adverse reactions. The most common type of adverse reaction was erythema multiforme (70%), followed by neutropenia (20%) and Stevens-Johnson syndrome (10%). In two patients a serious adverse reaction to trimethoprim-sulfamethoxazole led to the diagnosis of HIV infection. CONCLUSIONS: The overall incidence and type of serious adverse reactions to trimethoprim-sulfamethoxazole among infants and children with HIV infection appear to be similar to those among adults.     

Intraindividual variability in HIV infection: Evidence for greater neurocognitive dispersion in older HIV seropositive adults.

Objective: Both the prevalence and incidence of HIV infection among older adults are on the rise. Older adults are at increased risk of HIV-associated neurocognitive disorders, which have historically been characterized as an inconsistent or “spotty” pattern of deficits. Dispersion is a form of intraindividual variability (IIV) that is defined as within-person variability in performance across domains and has been associated with poorer neurocognitive functioning and incipient decline among healthy older adults. To our knowledge, no studies have yet examined dispersion in an aging HIV-infected sample. Method: For the current study we examined the hypothesis that age and HIV infection have synergistic effects on dispersion across a battery of clinical and experimental cognitive tasks. Our well-characterized sample comprised 126 HIV-seropositive individuals (HIV+) and 40 HIV-seronegative comparison individuals (HIV?), all of whom were administered a comprehensive neuropsychological battery. Results: Consistent with our hypothesis, an age by HIV serostatus interaction was observed, with the older HIV+ group demonstrating a higher level of dispersion relative to older HIV? and younger HIV+ individuals, even when potentially confounding demographic and medical factors were controlled. Conclusion: Our results demonstrate that older HIV+ adults produce greater dispersion, or intraindividual variability in performance across a range of tests, which may be reflective of cognitive dyscontrol to which this population is vulnerable, perhaps driven by the combined effects of aging and HIV infection on prefrontostriatal systems. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Sexual issues and aging within the context of work with older adult patients.

Recent studies suggest that the majority of older men and women maintain moderate or high levels of sexual interest well into their 70s but often experience sexual dysfunction. Given the burgeoning of the older adult population, psychologists are increasingly likely to find older patients in their practice with questions or concerns about sexuality. The goal of this article is to provide psychologists with current information regarding sexuality and aging, including general prevalence data, age-related biological changes (e.g., menopause), incontinence, erectile dysfunction, prostate changes, male performance-enhancing drugs (e.g., Viagra), medications' sexual side effects, and sexually transmitted diseases, including HIV/AIDS. Practice guidelines endorse a biopsychosocial perspective, in which stereotypes, gender, partner availability, socioeconomic status, ethnicity, religious beliefs, and sexual orientation are examined. Clinicians' potentially negative countertransference also should be recognized and worked through. Case examples illustrate many of these concepts, and directions for future research and patient care are offered. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Countertransference in child psychoanalytic psychotherapy: The emergence of the analyst’s childhood.

The author focuses on a particular type of countertransference with children—the emergence of the therapist’s childhood memories and experiences in child psychotherapy. The revival of these childhood recollections in the analyst is not a barrier or sign of pathology as previously held, but rather in some cases a vital resource that may potentially deepen and facilitate analytic work. The therapist’s memory and attendant fantasies, physical/sensory experience, and affect states in the context of the childhood memory may afford the analyst the opportunity to not only make contact with his or her “self” as a child, but also to further symbolize these states of mind and use them in the exploration of the child patient’s mind. Through intersubjective exchanges with the patient, the analyst’s childhood memories are given new meaning in the context of the therapeutic work with the child patient. The author highlights the uniqueness of countertransference with children as compared with adults. A detailed clinical vignette is presented, organized around the arrival of a memory from the analyst’s childhood and how the analyst made use of it in the transference/countertransference field. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Diagnostic interviewing with drug abusers.

Principles of diagnostic interviewing with adult male drug abusers are discussed in the light of changing concepts of addiction/dependency, confidentiality, and countertransference, and basic research relevant to each major content section is highlighted. A case example illustrates these ideas, and the article concludes with some practical recommendations for interviewing substance abusers. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Review of Countertransference in the treatment of PTSD.

Reviews the book, Countertransference in the treatment of PTSD, edited by John P. Wilson and Jacob D. Lindy (see record 1994-98036-000). This book purports to be the first to examine systematically the unique role of countertransference in working with victims of trauma. To help systematize clinical work with trauma victims, the contributors produced a theoretical model that attempts "to identify the core elements and dimensions of countertransference and their relationship to PSTD." The unique status of this book claimed by the editors is predicated on an assumption unexamined by the editors; namely, that the contributors have uncovered a new clinical phenomenon—countertransference to PSTD. This assumption rests on a second important and unquestioned assumption that the victims of PSTD suffer differently and more horribly than do other sufferers of the human condition. Haven't clinicians learned by now that suffering is suffering regardless of the external event that may have precipitated the hurt? If suffering is suffering, regardless of its provocation, then countertransference is countertransference regardless of the external events to which the clinician is responding. While this volume, by carefully delineating and systematizing a host of therapist responses to patient inductions, contributes to a better understanding of countertransference, it hasn't discovered a new clinical phenomenon. The value of this book resides in the thoughtful ways the contributors discuss monitoring one's countertransference and their compassionate and efficacious responses to the suffering of their patients. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Intake interviewing with suicidal patients: A systematic approach.

Assessment and management of suicidal patients is one of the most challenging and stressful tasks associated with the practice of psychology. This article provides information on how to conduct suicide assessment interviews and initial patient management within the context of an intake interview. A brief review of professional training issues and suicide risk factors precedes discussion of suicide assessment interviewing procedures. Strategies for evaluating depression, suicide ideation, suicide plan, self-control, and suicide intent are presented. General guidelines for initial management of and clinical decision making with suicidal patients are reviewed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Direct patient computer interviewing.

Proposes that recent developments in direct computer interviewing of patients in clinical settings range from comprehensive behavioral and psychiatric assessment and diagnostic systems to special topic interviews (e.g., suicide risk, drug and alcohol use, sexual dysfunction). Early trials with computer-based psychotherapy have now been extended to cognitive therapy for depression and patient education. Advantages of computer interviewing include high patient acceptance, low costs for routine interviewing, and balance of structure and reliability with flexibility and individualized question flow. It is suggested that research in this area move from demonstration and feasibility studies to the impact of patient interviews on clinical and research systems and studies of the interview process itself. (56 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Selective attention in a reaching task: Effect of normal aging and alzheimer's disease.

This study examined the ability of young adults, older adults, and older adults suffering from Alzheimer's disease (AD) to perform a selective reaching task. Normal aging did not increase interference caused by distractors. In contrast, patients with AD showed massively increased effects of distractor interference. AD patients showed a high probability of making responses to distractor items. The proportion of these incorrect responses was related to the inability to use inhibitory processes, which increased with the severity of AD. Responses to distractors occurred despite the fact that patients could discriminate targets and distractors and knew that their responses to distractors were in error. These data suggest that AD patients are impaired in their ability to inhibit incorrect responses. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Success and failure at dual-task coordination by younger and older adults.

Dual-task processing was explored in younger and older adults in 2 experiments that used a tone discrimination and a letter discrimination task. To encourage parallel processing if that was possible, the authors presented the stimuli for the 2 tasks simultaneously, and participants were instructed to withhold their responses until both were ready. The authors found no evidence for parallel processing and no evidence that the management of central processing of dual tasks is qualitatively different in older adults than it is in younger adults. When one response was verbal and the other manual, the 2 responses closely coincided. When both responses were manual, the authors did find that the first response was not delayed enough to coincide with the 2nd and that this underestimation was greater in older adults. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Depressive symptoms and lymphocyte proliferation in older adults.

In an 18-month prospective study, community-dwelling older adults, including both spousal caregivers of dementia patients and noncaregiving controls, were examined. Participants were selected on the basis of the presence or absence of chronic depressive symptoms that exceeded a cutoff score for clinically relevant depressive symptoms on a self-report symptom measure. Compared with nondepressed older adults, those with chronic, mild depressive symptoms had poorer T cell responses to 2 mitogens from baseline to follow-up. Additionally, among individuals with depressive symptoms, older age was associated with the poorest blastogenic response to the mitogens at follow-up. These findings extend the association between depression and immune function to community-dwelling older adults with chronic, mild depressive symptoms. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Countertransference play: Informing and enhancing therapist self-awareness through play.

The study of countertransference among therapists working with children and adolescents is a relatively recent phenomenon, but the lack of attention paid to resolving countertransference that arises during the course of play therapy is surprising. The most commonly suggested way to address countertransference in the literature is through the development of therapist self-awareness during verbal discourse in supervision. This article addresses the rationale for, and provides examples of, an active approach for dealing with potentially counter therapeutic reactions. This technique, known as countertransference play, derives from the field of art therapy and provides therapists with a logically derived means of understanding and working through countertransferential responses. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Assessment and management of pain in the older adult.

Objective: To discuss the unique issues related to pain in older adults and to outline methods for assessment and treatment of geriatric pain. Synthesis: A model for pain assessment and treatment in the older adult is presented. Existing data indicate that cognitive-behavioral treatments are effective for pain management in older adults, although modification in treatment procedures may be needed to optimize treatment outcome. Conclusion: Geriatric pain is an understudied and undertreated problem. Multidisciplinary assessment and treatment should focus on pain reduction, relieving emotional distress, and improving function, with the ultimate goal of reducing disability and improving quality of life. Severe, disabling pain is not part of normal aging and should be assessed and treated. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Schema reliance for developmental goals increases from early to late adulthood: Improvement for the young, loss prevention for the old.

People tend to encode and retrieve information in terms of schemata, especially when processing resources are low. This study argues that the life-span schema about developmental goals constitutes a generalized expectation about the life course that associates young adults with growth and older adults with loss prevention. Predictions were that young and older adults possess this schema; that both age groups rely on it when remembering age-associated information about goals; and that this schema reliance is particularly pronounced among older adults, due to age-related difficulties in overcoming schemata. In Experiment 1, participants assigned growth or loss-prevention orientations to young and older faces and adhered to the life-span schema. In Experiment 2, participants were presented young and older faces paired with growth or loss prevention. When later asked to recognize faces and remember goal orientations, participants were more likely to remember young faces with growth and older faces with loss prevention than vice versa. This effect was more pronounced among older adults. Conclusions are that reliance on life-span schemata when remembering developmentally relevant information increases with age. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The care of HIV-infected adults in the United States. HIV Cost and Services Utilization Study Consortium

BACKGROUND AND METHODS: In order to elucidate the medical care of patients with human immunodeficiency virus (HIV) infection in the United States, we randomly sampled HIV-infected adults receiving medical care in the contiguous United States at a facility other than military, prison, or emergency department facility during the first two months of 1996. We interviewed 76 percent of 4042 patients selected from among the patients receiving care from 145 providers in 28 metropolitan areas and 51 providers in 25 rural areas. RESULTS: During the first two months of 1996, an estimated 231,400 HIV-infected adults (95 percent confidence interval, 162,800 to 300,000) received care. Fifty-nine percent had the acquired immunodeficiency syndrome according to the case definition of the Centers for Disease Control and Prevention, and 91 percent had CD4+ cell counts of less than 500 per cubic millimeter. Eleven percent were 50 years of age or older, 23 percent were women, 33 percent were black, and 49 percent were men who had had sex with men. Forty-six percent had incomes of less than $10,000 per year, 68 percent had public health insurance or no insurance, and 30 percent received care at teaching institutions. The estimated annual direct expenditures for the care of the patients seen during the first two months of 1996 were $5.1 billion; the expenditures for the estimated 335,000 HIV-infected adults seen at least as often as every six months were $6.7 billion, which is about $20,000 per patient per year. CONCLUSIONS: In this national survey we found that most HIV-infected adults who were receiving medical care had advanced disease. The patient population was disproportionately male, black, and poor. Many Americans with diagnosed or undiagnosed HIV infection are not receiving medical care at least as often as every six months. The total cost of medical care for HIV-infected Americans accounts for less than 1 percent of all direct personal health expenditures in the United States.     

Memory and Emotions for the September 11, 2001, Terrorist Attacks in Patients With Alzheimer's Disease, Patients With Mild Cognitive Impairment, and Healthy Older Adults.

National traumatic events can produce extremely vivid memories. Using a questionnaire administered during telephone interviews, the authors investigated emotional responses to, and memory for. the September 11, 2001, terrorist attacks in patients with Alzheimer's disease (AD), patients with mild cognitive impairment (MCI), and healthy older adults in the initial weeks following the event and again 3-4 months later. There were several notable findings. First, patients with AD showed less memory than patients with MCI and older adults. Second, patients with AD, but not patients with MCI or older adults, appeared to retain more memory for personal versus factual information. Third, patients with AD and older adults did not differ in the intensity of their reported emotional responses to the attacks, whereas patients with MCI reported relatively less intense emotional responses. Last, distortions of memory for personal information were frequent for all participants but were more common in patients with AD. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Milieu countertransference in treatment of borderline patients.

Describes milieu countertransference as a collective phenomenon in which the treatment staff as a group experiences regressions in functioning that, because of the operation of the patient's ego defenses, essentially mirror the level of functioning in the patient. When properly identified and treated, the milieu countertransference can benefit treatment both as a means to better understand the patient's experience and as a tool for active intervention in remediation of the patient's pathological development. A case report, involving a 14-yr-old male, is presented to illustrate the issues and interventions involved in the milieu countertransference developed in the treatment of a borderline patient. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Aging, dementia and automobile driving

According to Norwegian law, drivers 70 years and older must carry a health certificate. This is issued by a general practitioner. If the patient is not supposed to drive because of a medical condition, the doctor should report this to the County Health Officer. This can be problematic, not only because assessing whether a patient fulfills the criteria for driving is difficult, but also because the doctor has obligations to both the public and his patient. These problems are discussed, based on assessment of available literature and on personal experience. Dementia is common in old age and affects approximately 15% of persons aged 75 and older. Patients with moderate and severe dementia should certainly not drive. However, some patients with mild dementia can nevertheless be safe drivers. The problem, however, is to identify the safe drivers among patients with mild dementia. The current regulations on dementia and driving are presented briefly.