Individual Psychoanalytic Psychotherapy Research Articles

Patient‐reported reasons for discontinuing psychotherapy in a low‐cost psychoanalytic community clinic

AbstractUsing data from an outcome study of adult individual psychoanalytic psychotherapy, conducted in a low‐cost Australian clinic, a mixed‐methods approach was employed to investigate patient discontinuation. This paper addresses the qualitative component of the discontinuation study, which explored patients’ reasons for leaving the clinic service upon assessment or in treatment proper. Of 205 patients commencing clinic contact, 41% discontinued during or shortly after the four‐week assessment period, while 40.5% of patients beginning psychotherapy withdrew before reaching the two‐year treatment limit. Across these two groups, former patients were interviewed about their therapy experience and decision to discontinue. Thematic analysis of 20 interview transcripts generated five descriptive categories of discomfort or dissatisfaction prompting discontinuation: clinic factors, therapist factors, patient factors, therapist–patient relationship factors and therapy factors. Findings suggest that experience of the clinic setting itself, together with negative patient perceptions of therapists and therapist interactional style, weres significant influences and that dissatisfaction with the psychotherapy process and outcome was more relevant than problematic patient factors in treatment withdrawal. A number of patients, mainly late discontinuers, reported positive experiences of psychotherapy and significant treatment gains. Implications of the findings, with specific emphasis on psychoanalytic treatment settings, are discussed.

It Takes a Village to Grow a Person: A Case of a Psychoanalytic Treatment in a Hospital Setting

ABSTRACTIn today’s culture of evidence-based treatment and managed care, psychoanalysis is mostly relegated to the private consulting rooms of psychoanalysts, no longer available in hospital settings for those who need more containment than a single psychotherapist can offer. At the Austen Riggs Center, we work with our patients in four-times-a-week individual psychoanalytic psychotherapy and use psychoanalytic ideas about groups and their processes to understand the individual’s role in social context, particularly within their family system. Working psychoanalytically within a larger system raises interesting questions about the role and nature of transference and countertransference when it is not solely emerging between patient and analyst, but rather with many people across situations. Whereas the consulting room remains a privileged space for the patient to work as an individual, the therapeutic community offers a different kind of consulting room, a social space where therapist or analyst also participates alongside his or her patients. Such a setting requires that one think about how to integrate experiences in the social realm into the fantasy space of psychoanalytic psychotherapy. This paper offers a window into the nuances of such a treatment in our hospital setting and illustrates the process of synthesizing the wealth of information gleaned from such an immersive treatment environment.

Cracking the Intrapsychic “Glass Ceiling” for Women in Leadership: Therapeutic Interventions

ABSTRACTThe number of women holding elite-level positions in politics and business have significantly increased in recent years, but the lack of parity between the genders is still apparent. This article addresses the stereotypical thinking and the double-bind dilemma women face in obtaining promotions to top positions. It posits internal obstacles that stem from early socialization and may be worked through therapeutically. It proposes that individual psychoanalytic psychotherapy, in the context of object relations and attachment theories, combined with group therapy can facilitate intrapsychic growth towards leadership. Participation in a time-limited group for women may further their insight into the underlying barriers to top positions and facilitate the learning of how to move from fitting in to having a voice and becoming more independent and assertive. Women cracking the glass ceiling may contribute to external societal changes as the relational style of women will continue to gain momentum and redefine leadership in the workplace. Clinical examples will illustrate the therapeutic interventions.

Psychoanalysis Against Fascism: Fascism, Terrorism, and the Fascist and Terrorist Within

With the rise of frightening and public xenophobia, racism, and anti-Semitism; the ubiquity of terror; and the spreading, cold indifference of globalization, we must ask ourselves: What is the social role of private, individual psychoanalytic psychotherapy? In this paper, I explore both the psychic structures of sociopolitical fascism and terrorism as well as the structures of fascism and terrorism within our psyches. Through the work of Gilles Deleuze, Félix Guattari, and other theorists, interlinked with clinical vignettes, I explore the potential for the psychoanalytic session to generate a resistant, enlivening response to the violence of subjugating political-psychic systems.

Don’t tell me I’m normal: inpatient psychotherapy of a severely abused patient at the Cassel Hospital

This paper is a case study of a patient with severe personality disorder undergoing treatment at the Cassel Hospital. It looks at a phase of her individual psychoanalytic psychotherapy and how that sits within an institutional model of treatment that can be understood as applied psychoanalysis, in which Tom Main’s concept of a ‘culture of enquiry’ aims to observe and bring together splitting and projective processes operating at all levels of the organisation. The patient, who had been sexually abused and then suffered a prolonged suicidal breakdown, exerted intense pressure on the institution through her experience of herself as both a victim of abuse and a participant in it. A working through is described, in which different parts of the patient that had been projected into different parts of the institution are brought together, and her primitive demand for a two-person world gives way to an acceptance of triangulation. Themes from her individual sessions are enacted in the milieu-based treatment, and conversely struggles in the patient community appear in her sessions. It is from drawing these parts of the patient together as a whole institution that the treatment derives its power and effectiveness.

Therapists' view of therapeutic action in psychoanalytic psychotherapy with young adults.

Studying experienced therapists' implicit theorizing may contribute to our understanding of what is helpful and what hinders treatment with particular patient populations. In this study, 16 therapists' views of curative factors, hindering factors, and outcome were explored in 22 interviews conducted at termination of individual psychoanalytic psychotherapy with young adults. Grounded theory methodology was used to construct a tentative model of therapeutic action based on the therapists' implicit knowledge. The results indicated that developing a close, safe and trusting relationship was viewed as the core curative factor in interaction with the patient making positive experiences outside the therapy setting and the therapist challenging and developing the patient's thinking about the self. The therapeutic process was experienced as a joint activity resulting in the patient becoming a subject and acquiring an increasing capacity to think and process problems. The patient's fear about close relationships was seen as hindering treatment and leading to core problems remaining. The model is discussed in relation to major theories of therapeutic action in the psychoanalytic discourse and previous research focusing on young adults' view of curative and hindering factors in psychotherapy. Implications for practice and further research are suggested.

Effectiveness of child psychoanalytic psychotherapy in a clinical outpatient setting

The objective of this study was to evaluate the outcome of child psychoanalytic psychotherapy in a clinical outpatient setting in a city in southern Brazil. Three psychological tests (Rorschach, Bender and WISC III) were administered to 23 children, aged 6–11 years old, and the Child Behaviour Check List (CBCL) was completed by the parents. All testing was completed before the beginning of the individual psychoanalytic psychotherapy. The same measures were repeated after 12 months of intervention. The 23 children who received individual psychoanalytic psychotherapy were compared with a control group who did not receive any kind of intervention. In the clinical group, the results indicated a statistically significant reduction of anxiety symptoms (0.002) and school problems (0.031), improvement in interpersonal relationships (0.022), and positive change in the following CBCL scales: withdrawn (0.010), thought problems (0.022), anxiety and depression (0.017), internalising (0.008) and total (0.003). An effect size of 0.696 was calculated based on the CBCL total scale before and after the intervention. The results revealed that child psychoanalytical psychotherapy is mostly effective in the treatment of female children who present internalising disorders.

Abandono de psicoterapia com crianças

OBJETIVO: Comparar uma amostra de 24 crianças que completaram 12 meses de psicoterapia psicanalítica com uma amostra de 38 crianças que interromperam prematuramente o tratamento. MÉTODO: Trata-se de um estudo quantitativo em dois grupos de crianças; tratamento quase-experimental de medida única antes do início da psicoterapia psicanalítica individual. RESULTADOS: Foram encontradas diferenças estatisticamente significantes nas seguintes variáveis: sexo, sintomas, frequência dos atendimentos, capacidade da criança de controlar as emoções e os impulsos, medida pelo teste Rorschach e nas escalas de sociabilidade, queixas somáticas e comportamentos internalizantes, tais como ansiedade e depressão, medidas pelo Child Behavior Checklist. CONCLUSÕES: Este estudo revelou que a psicoterapia psicanalítica é efetiva no tratamento da criança do sexo feminino que apresenta transtornos internalizantes, tais como ansiedade e depressão, tem maior descontrole de emoções e impulsos e recebe atendimento com uma frequência de duas vezes por semana por pelo menos 12 meses.

Psicoterapia di coppia - Psicoterapia di gruppo Una dialettica possibile?

- Through the exploration of the "bond" concept (as expressed by Kaës) - which is the specific unconscious reality that emerges from the encounter of two or more subjects - work with couples is analyzed through the evolution of what the authors see as the most fruitful paradigms for clinical work. Our understanding of individual and group psychoanalytic psychotherapy is examined, and basic clinical theoretical tenets are identified during the meeting with the couple. We determine the cardinal concepts by which we explore the evergrowing complexity of emotional dynamics. The therapist needs to observe and investigate both inner and outer personal aspects, as well as reciprocal emotional dynamics in order to define not only the self but also the meaning of us. The authors examine different phases in the couple's life, and, more specifically, what happens within the couple when a newborn arrives. Particular attention is given to the construction of the couple's common setting. Referring to transference and counter-transference dynamics, analogies and differences between group psychotherapy and couple psychotherapy are outlined in order to establish a possible dialogue between the two approaches.Key words: bond, couple, group, transference, counter-transference, unconscious group organizers.

Effectiveness of Psychoanalytic Psychotherapy for Adolescents with Serious Mental Illness: 12 Month Naturalistic Follow-Up Study

The aim of this naturalistic longitudinal study was to examine the effectiveness of individual psychoanalytic psychotherapy in reducing symptoms and improving overall functioning for adolescents with severe mental illness beyond the changes observed with treatment as usual. Changes to family functioning were also examined. Participants at 12 month follow up were 55 of an initial group of 80 Child and Adolescent Mental Health Services patients with complex, severe mental illness (32 female, mean age = 15.11 years). At initial assessment 40 participants were offered psychoanalytic psychotherapy when a psychotherapist became available; 23 accepted and received once- or twice-weekly psychoanalytic psychotherapy for 4-12 months. Out of the initial 57 participants who received Child and Adolescent Mental Health Services treatment as usual, 33 were reassessed at 12 months. Self-reported depressive symptoms, parent-reported social and attention problems and researcher-evaluated overall functioning and family functioning were measured at initial assessment and 12 months later. At 12 months, psychotherapy was associated with a greater reduction in depressive, social and attention problems than treatment as usual, alone, if these problems were initially in the clinical range. There was no effect on participant overall functioning or family functioning. This naturally occurring sample of seriously ill adolescents referred to Child and Adolescent Mental Health Services for assessment were suffering complex mental illness and poor mental health. Empirical evidence is presented that psychoanalytic psychotherapy is an effective addition to Child and Adolescent Mental Health Services treatment as usual for mental illness in adolescence, particularly for more severe and complex cases. The naturalistic study design and participant attrition are possible study limitations.

Young people's experiences of individual psychoanalytic psychotherapy

Greater emphasis is currently being placed on user involvement in shaping the delivery of mental health services and the need for increasing the evidence base for psychotherapeutic interventions such as individual psychoanalytic psychotherapy (IPP). This qualitative study reports on the range of experiences of six young people aged between 16 and 21 years in undertaking IPP. Interpretative phenomenological analysis was used to develop an in-depth understanding of their experiences. The themes identified the young people's initial expectations and concerns about starting psychotherapy, experiences of learning the ropes of therapy and the process and meaning of ending therapy. The affective relationship with the therapist was of particular importance to the young people concerned. Positive experiences of IPP included being listened to and being accepted, and talking and thinking in depth. The power differentials with respect to being a patient were also evident. The paper concludes by suggesting that paying greater attention to young people's views of psychotherapy may improve their initial engagement and help to develop services in more appropriate ways. Qualitative methodologies provide a useful adjunct to conducting process and outcome research in this context.

LEARNING OUR LESSONS: SOME ISSUES ARISING FROM DELIVERING MENTAL HEALTH SERVICES IN SCHOOL SETTINGS

This paper describes some of the complexity of providing Child and Adolescent Mental Health Services (CAMHS) input into school settings. Some reference is made to previous writing about psychotherapeutic work with schools, and also to recent government policy changes which are impacting on service delivery. There is discussion of the multiple levels at which interventions need to be conceptualized, and the issues arising when working within systems and organizations that have very different drivers, tasks, aims and cultures. It is argued that, given the complexity of the therapeutic task, clinicians need a high level of experience and robustness, and to be armed with understanding gleaned not just from individual psychoanalytic psychotherapy but also from psychoanalytic thinking about organizations, as well as about therapeutic communities, in order to function effectively. There is discussion of some of the typical institutional defences against anxiety and distress that arise when working with the most complex children and families in schools, and in particular the pressure to locate problems within individuals and to attempt to address such issues on an individual basis while leaving the institutional and systemic issues unaddressed. I suggest that such work demands a complex view of the role of the therapist, which includes taking on a role which has some similarities to working in therapeutic communities. Some vignettes are used to illustrate how one can do effective and useful clinical work with individual children, and with their families when wider systemic issues are taken seriously.

Outcome of Psychoanalytically Oriented Outpatient Treatment of Borderline Personality Disorder

This study examines the outcome of up to fifteen months of psychoanalytically oriented psychotherapy (primarily based on object relations and attachment theory) for patients with borderline personality disorder. Nineteen patients with borderline personality disorder, diagnosed by an experienced psychiatrist as part of the general clinical evaluation, were offered two years of treatment in an outpatient setting. Treatment included individual psychoanalytic psychotherapy, psychoanalytic group therapy, and group-based psychoeducation. Outcome was measured with a battery of self-report questionnaires: the Beck Anxiety Index (BAI), the Beck Depression Inventory (BDI), and the Symptom Check-List (SCL-90-R). Analyses focused primarily on the first fifteen months of treatment. The dropout rate was relatively high, but patients who remained in treatment (N=11) reported statistically significant positive changes in levels of anxiety and depression and general level of functioning. We found no significant differences between the group of patients who remained in treatment and those who dropped out. Follow-up data for up to 32 months indicated not only that the positive changes observed were maintained, but that patients who completed at least fifteen months of treatment reported additional improvements in the follow-up period.

Facteurs d'évolution des thérapies psychodynamiques en pédopsychiatrie

Psychodynamic therapies in child psychiatry do not only come down to individual psychoanalytic psychotherapy. New care settings like “family group conversations” or « parent–child therapeutic consultations » have been developed keeping a strong link to psychoanalytic theory. We propose here an overview of the various factors that occurred in this historical evolution of practices. We then examine what are today the role and the limits of individual psychoanalytic psychotherapy in psychodynamic treatment in child psychiatry.

Combination of psychotropics in psychoanalytic psychotherapy: psychotherapeutic challenges

The case illustration is from a long-term experience of individual psychoanalytic psychotherapy with a male patient, who started therapy when he was 15-years- old. According to DSM-IV criteria, he was diagnosed with a major depressive disorder. A psychological assessment including a Rorschach test showed a poorly integrated but well-adapted Borderline-Narcissistic personality disorder. Various classes of ant-idepressant drugs were used with equivocal or uncertain effects, and the roots and causes of the patient's negative reactions to medication had to be thoroughly investigated and dealt with during psychotherapy. Pharmacotherapy might succeed in targeting the various symptoms of depressive states, but the psychodynamic approach in a psychotherapeutic relationship widens the scope and works introspectively, allowing the patient insights to understanding the symptoms. The use of a psychotropic agent is usually based on trust and belief in its expected effect, but often the effect is not as expected. The psycho- pharmacological drug is also imbued with manifest and latent meanings which can be reached at in the psychoanalytic report. Such meanings and expectancies, and the consequent reactions affect both the patient and the psychotherapist. They have to be dealt with and overcome by psychoanalytic understanding and intervention, as well as experience and skill in use of the medicine concerned.

Psychiatry, 2nd ed.

Psychiatry, 2nd ed.

Treating Personality Disorders in Children and Adolescents: A Relational Approach

Treating Personality Disorders in Children and Adolescents: A Relational Approach

A psychoanalytically oriented combined treatment approach for severely disturbed borderline patients: The Athens project

A psychoanalytically oriented combined treatment is considered beneficial for severely disturbed borderline patients, especially during an acute crisis. The proposed treatment comprises hospitalization and specialized psychotherapeutic inpatient treatment, individual psychoanalytic psychotherapy, and psychiatric management. It is important to take into account that during inpatient treatment, projective identifications and splitting mechanisms are activated, involving different members of the therapeutic personnel or other patients. The mental health team--the psychiatrist, the nurses, the assigned psychotherapist, and other members of the therapeutic personnel--should work together in the context of teamwork in order to explore transference and countertransference manifestations. This function promotes empathy and understanding of the patient's inner difficulties. A combined treatment approach can help the patient stabilize his or her condition and develop awareness and motivation for undertaking long-term treatment and individual psychoanalytic psychotherapy, with the prospect that therapy will be maintained after the patient's discharge.

Childhood depression: Work in progress

This paper presents preliminary findings from two children who were offered time-limited individual psychotherapy in London as part of a three-centre, ERC BIOMED funded prospective outcome study on childhood depression. The study was co-ordinated from London, the other centres being Athens and Helsinki. The comparative design of the study is described, as well as the research instruments used. The children were offered 30 sessions of manualized individual psychoanalytic psychotherapy, which were tape-recorded; parents were offered 15 sessions of parallel parent work. Both children showed substantial improvement on the instruments used to assess depression, including a marked sleeper effect on follow-up; their mothers' attitude towards them became less enmeshed and critical. A preliminary qualitative analysis suggests that the Childhood Depression Inventory, one of the instruments used, selects a population of depressed young people who are characterized by particularly salient existential anxiety. Cet article présente les résultats préliminaires des psychothérapies individuelles à durée déterminée proposées à deux enfants londoniens; cette prise en charge fait partie d'un projet de recherche sur les résultats potentiels des traitements de la dépression chez l'enfant. Financé par le Centre pour l'éducation et la Recherche - Biomed, il se déroule dans trois centres: la coordination globale s'effectue à Londres, tandis que les deux autres centres se trouvent à Athènes et à Helsinki. Le schéma comparatif est décrit dans cet article, ainsi que les instruments de recherche employés. On propose aux enfants trente séances de psychothérapie psychanalytique individuelle; les thérapeutes s'inspirent des consignes d'un manuel standardisé et les séances sont enregistrées sur support magnétique. En parallèle, quinze séances sont proposées aux parents des enfants concernés. Les progrès faits par chacun des enfants sont considérables, comme en témoignent les résultats obtenus aux tests employés pour mesurer la dépression. On constate par ailleurs un "effet dormant" certain - le suivi de contrôle montre la persistance de ces progrès même aprés la fin du traitement. Parallèlement, les mères se sentant moins enchevêtrées, leur attitude envers leur enfant devient moins négative. L'analyse qualitative préliminaire laisse penser qu'un des instruments employés, l'Inventaire de Dépression chez l'Enfant, fait ressortir un échantillon de jeunes dépressifs caractérisés par des angoisses existentielles particulièrement vives. Questo articolo presenta i risultati preliminari della terapia individuale a tempo definito di due bambini a Londra all'interno di un lavoro di ricerca sulla depressione infantile finanziato dal ERC BIOMED in tre centri. IL lavoro e' stato coordinato da Londra e gli altri due centri sono Atene e Helsinki. Nell'articolo si descrive il programma comparativo del lavoro e gli strumenti di ricerca usati. Ai bambini si offrirono 30 sedute di psicoterapia infantile individuale registrate mentre ai genitori furono offerte 15 sedute di lavoro con i genitori in parallelo. In entrambi i casi per i bambini ci fu un miglioramento sostanziale rivelato dagli strumenti utilizzati per individuare la depressione, compreso un notevole effetto sleeper ad un controllo successivo; l'atteggiamento delle madri verso di loro divenne meno critico e piu' libero. Un'analisi quantitativa preliminare sembra suggerire che il Childhood Depression Inventory, uno degli strumenti usati, selezioni la popolazione giovanile depressa caratterizzata da una notevole ansia esistenziale. Dieser Artikel präsentiert vorläufige Ergebnisse von zwei Kindern, denen zeitlich begrenzte individuelle Psychotherapie in London als Teil einer prospektiven Ergebnisstudie über Kindheitsdepression, die ERC BIOMED finanziert und an drei Zentren durchgeführt wird, angeboten wurde. Die Studie wird von London koordiniert und die anderen Zentren sind Athen und Helsinki. Es werden das vergleichende Design der Studie wie auch die Forschungsinstrumente, die benutzt werden, beschrieben. Den Kindern wurden 30 Stunden individueller psychoanalytischer Psychotherapie gemäss eines Manuals angeboten, die auf Band aufgenommen wurden; den Eltern wurden 15 Stunden paralleller Elternarbeit angeboten. Beide Kinder zeigten wesentliche Verbesserungen bei den Instrumenten, die benutzt wurden, um Depression zu messen, einschliesslich einer markanten 'sleeper' Wirkung bei follow-up: die Haltung ihrer Müter zu ihnen war weniger verworren und kritisch. Eine vorläufige qualitative Analyse schlägt vor, dass das Childhood Depression Inventory, eines der Instrumente, die benutzt wurden, eine Population von depressiven jungen Leuten selektiert, die durch besonders hervorstechende existentielle Angst charakterisiert waren.

Learning Disability as a Refuge from Knowledge

In this paper the author finds that an important factor preventing learning and development in learning disabled people is the way in which their learning disability can act as a refuge from knowledge. He begins by discussing how the very term 'Learning Disability', through obscuring the distinction between organic and psychological difficulties in learning, can itself become a refuge for those who use the term from facing the reality of damage and deficiency. Following this, he considers the development of psychological impairments to learning from a psychoanalytical perspective. He places particular emphasis on how the emotional consequences of a child's handicap, to the child him/herself and his/her parents, can affect the development of curiosity and learning. The author illustrates these ideas with clinical material from individual psychoanalytic psychotherapy with an adolescent boy with a learning disability.