Patients In Psychoanalysis Research Articles

Beyond Informed Consent: Talking to Patients About Therapeutic Action.

Psychodynamically oriented psychotherapists are faced with the question of what to say to new patients about the therapy they are beginning. This article reviews historical attitudes about early treatment discussions with patients in psychoanalysis with an emphasis on how these discussions have evolved as informed consent became a standard of care. Approaches to talking to patients about therapeutic action in psychodynamic psychotherapy are discussed, including the development and application of a psychoeducational document that is being used to facilitate these discussions in the outpatient residents' clinic of a large urban academic medical center. Finally, qualitative data are presented to describe residents' experiences with this document. The overwhelmingly positive responses suggest that this intervention is helpful for patientsandresidents and can serve to deepen the treatment relationship through mutual trust and understanding.

PHENOMENON-STRUCTURAL PSYCHOPATHOLOGY APPLIED TO PERIPATETIC GROUP THERAPY

Peripatetic therapy, also known as therapeutic accompaniment, emerged as a form of supplementary secondary support for psychiatry, psychology and psychoanalysis patients that did not adapt to conventional clinical and hospital care modalities. The practice was notable for its non-stationary therapeutic setting, which went beyond the doctor's office or health care institution, and peripatetic group therapy has emerged as one of the ramifications of its evolutionary process. After maturing over the decades, it has now become an independent therapeutic alternative whose results often differ significantly from those of conventional psychotherapy by integrating the territorial element into therapeutic care. The study discusses a peripatetic group therapy project carried out with patients of a mental health day hospital in Brasilia, Brazil. Results are presented based on qualitative records of action research aimed at understanding the genesis and group dynamics processes involved and the application of phenomenon-structural psychopathology to the activity participants’ individual understanding of their lived experience of time and space, as well as of their own illness. The therapeutic activity, offered by the day hospital on a weekly basis (four hours per session), was observed over a period of six months. It was possible to identify that the transference relationships established between patients and therapists were a crucial element in allowing the activity to take place and participants to cope with the stress of being outdoors, far from the institutional therapeutic setting they were accustomed with. The group sessions also helped some patients exercise greater autonomy than in their households, including by providing care to other patients with less autonomy. It was also possible to note that working physically outside of conventional clinical settings makes it possible to acquire unique insights into patients and the different ways through which they experience the world. The positive results of patient interactions within and outside the group while carrying outdoor activities, their increased autonomy and the better understanding we have acquired of them allowed us to clearly envisage the importance of continuing research on what is still a little-explored topic.

Fostering change in personality configurations: Anaclitic and introjective patients in psychoanalysis.

Treatment goals in psychoanalysis often include changes in underlying psychological structures. Different patterns of change have been demonstrated in anaclitic and introjective patients. In a series of 14 cases, we took a further step and examined changes in the anaclitic - introjective personality configurations following psychoanalysis, as well as patients' experiences of these changes. Clinical case formulations were based on repeated interviews and the application of prototype-matching methodology. Patients' experiences were explored by applying inductive thematic analysis. We found a development toward more mature levels of differentiation and individuation in the anaclitic group, whereas relatedness and intimacy remained problematic in some introjective cases. Patients described their experienced changes in terms of complementary personality configuration, but the introjective group described more benefits from psychoanalysis. Several patients expressed their ambivalence toward these changes and a feeling of loss of their former selves. Patients' view of their analysts and the analytic method were congruent with patients' primary personality configuration. To reactivate developmental processes, the psychoanalytic technique has to be adjusted to the anaclitic and introjective patients' different needs and defenses.

On Love and Melancholia in Marguerite Duras’s Autofiction

In the Durassian melancholic atmosphere, past and present, fantasy and reality come together as one. This paper addresses the themes of love and destruction in Marguerite Duras’s life that pervade her oeuvre, allowing us to discern a melancholic structure within her autofiction. Writing down her melancholia—the impossible mourning of a loved object—Duras captures nothingness and loss—in order not to die of love. In a constant exchange with her readers, she searches for herself and delivers herself to her readers. This renewable creative process of writing enables her to engage in an ongoing experience of identity reconstruction, in a way similar to the patient in psychoanalysis re-creating his/her life’s fiction.

On the Prescribing Analyst

The value of medication for some patients in psychoanalysis serves to highlight the potential challenges of the medical analyst and invites exploration into possible motivations for assuming the prescribing role. Prescribing medication is one way in which the medical analyst integrates the dual identities of physician and analyst while dealing with significant cultural influences and intrapsychic tensions. Technical challenges posed by assuming the prescribing role are explored, as are the potential benefits of split treatment. The educational implications of this argument are discussed in relation to identity formation for candidates who are physicians.

The Current State of the Empirical Evidence for Psychoanalysis

After participating in this educational activity, the reader should be better able to evaluate the empirical evidence for pre/post changes in psychoanalysis patients with complex mental disorders, and assess the limitations of the meta-analysis. The effectiveness of psychoanalysis is still a controversial issue, despite increasing research efforts. To investigate the empirical evidence for psychoanalysis by means of a systematic review of the literature and a meta-analysis of the research data. A systematic literature search was undertaken to find studies regarding the effectiveness of psychoanalysis, published between 1970 and 2011. A meta-analysis was performed. Fourteen studies (total n = 603) were included in the meta-analysis. All but one were pre/post cohort studies. At treatment termination, the mean pre/post effect size across all outcome measures was 1.27 (95% confidence interval [CI], 1.03-1.50; p < .01). The mean pre/post effect size for symptom improvement was 1.52 (95% CI, 1.20-1.84; p < .01), and for improvement in personality characteristics 1.08 (95% CI, 0.89-1.26; p < .01). At follow-up the mean pre/follow-up effect size was 1.46 across all outcome measures (95% CI, 1.08-1.83; p < .01), 1.65 for symptom change (95% CI, 1.24-2.06; p < .01), and 1.31 for personality change (95% CI, 1.00-1.62; p < .01). A limited number of mainly pre/post studies, presenting mostly completers analyses, provide empirical evidence for pre/post changes in psychoanalysis patients with complex mental disorders, but the lack of comparisons with control treatments is a serious limitation in interpreting the results. Further controlled studies are urgently needed.

Changes in symptoms and interpersonal problems during the first 2 years of long‐term psychoanalytic psychotherapy and psychoanalysis

Longitudinal measurements can provide important information regarding variations in developmental trajectories of patients in long-term treatment. The present study investigated changes in general symptoms, depression, anxiety, and interpersonal problems during the first 2 years of long-term psychoanalytic psychotherapy (PP) and psychoanalysis (PA). It was expected that interpersonal problems would diminish more slowly compared to symptomatic dysfunction. An accelerated longitudinal design with five consecutive measurement points across two cohorts of patients was used. Changes on the Symptom Checklist-90-R (SCL-90-R), Beck Depression Inventory-II (BDI-II), State-Trait Anxiety Inventory (STAI), and Inventory of Interpersonal Problems-64 (IIP-64) were investigated during the first 2 years of long-term PP (n = 73) and PA (n = 40). Linear regression analysis was performed to model the different courses of improvement. After 2 years of treatment, patients in both groups still presented moderate to high levels of symptoms and interpersonal problems compared to non-clinical populations. As expected, interpersonal problems changed less rapidly. PP patients changed both with regard to symptomatic and interpersonal problems, whereas the only significant change in the PA group was on one of the symptomatic subscales. Slopes in the PA group and in PP group did not differ significantly from each other, except for the IIP-64 scale intrusive, with PP patients showing significantly more improvement than PA patients. The height of intake values of the outcome variables appeared to predict the speed of symptomatic recovery. Symptoms and interpersonal problems did not decrease notably within the first 2 years of psychoanalytic treatment. This is consistent with the idea that significant change takes time for patients with chronic mental disorders and personality pathology. In regular practice, it is advisable to monitor changes routinely in order to identify slow responders more quickly and change the treatment plan, if necessary.

Mental health characteristics of patients assigned to long-term ambulatory psychoanalytic psychotherapy and psychoanalysis in the netherlands

The present study investigated mental health characteristics of 170 patients assigned to long-term psychoanalytic psychotherapy (PP) versus psychoanalysis (PA) across treatment and studies. Both univariate and multivariate statistics showed that the main difference between treatments was found in the interpersonal domain. PA patients reported significantly more interpersonal problems (as measured by the Inventory for Interpersonal Problems-64), scored higher on the avoidant coping style and lower on the perceptual thinking index of the Rorschach-Comprehensive System, and scored lower on Aggressiveness and Psychoticism Minnesota Multiphasic Personality Inventory-2 PSY-5 scales compared with PP patients. Compared with psychoanalytic patients in other studies, our patients had similar levels of mental health problems, although not always in the same health areas. Limitations of the study were noted, such as the lack of outcome data and other comparison groups.

The Challenge of Chronic Pain: A Psychoanalytic Approach

Although patients with medically unexplained chronic pain are sometimes referred for psychiatric consultation, it is rare for them to be recommended for a psychoanalytically informed treatment. Moreover, because they experience their distress as primarily physical, it is difficult to engage such patients in psychoanalysis. Nonetheless, the psychoanalytic understanding of conversion symptom formation, and of how childhood trauma and adverse attachment experiences impact on the mind-brain-body-complex, can be integrated with the current neuromatrix theory of pain and thereby offer a comprehensive theoretical model and guide for the psychoanalytic treatment of some patients with chronic pain syndromes. The author illustrates this approach by reporting the analysis of a patient with chronic pelvic pain who had obtained no relief from a host of medical and psychiatric therapies. The analytic process of linking the pain with emotional trauma and pathologic internal object relations, and thereby symbolizing the pain, allowed the patient to discover multiple meanings for the symptom and make important life changes as the pain subsided.

Utopic ideas of cure and joint exploration in psychoanalytic supervision

The idea of the decisive and complete cure is deeply rooted in our unconscious and in the sacral roots of symbolic healing. Double sets of private theories of cure can frequently be found among patients in psychoanalysis and their analysts. The utopian cure involves a profound transformation of the personality by way of deep regression. The idea of an attainable and more limited cure includes new ways of managing old problems. The actual ongoing treatment is then seen as the ‘next‐best solution’. The utopian fantasy of creating ‘the new person’ by means of ‘proper’ psychoanalysis or analytic training has far‐reaching consequences for psychoanalytic education and supervision. Our awareness of the inevitable temptation in the ‘utopian state of mind’ can help us to trace and focus on utopic elements in the supervisory process. Exploration of utopic ideas of all the three parties involved can itself be a fruitful and stimulating way of working in supervision. An important aim of psychoanalytic supervision is to promote a distinct state of mind that can counterbalance utopic ideas and counteract the phenomenon of a ‘false analytic self’.

Long-Term Psychoanalytic Therapy as a Life-Saving Procedure

A dramatic long-term psychoanalytic treatment of a psychotic character disorder is presented in detail. This patient began therapy with a long standing history of an eating disorder for which she had received many hospitalizations and forms of treatment without any success. She was in a deep despair and as a last resort agreed to a psychoanalytic therapy. During the many years of treatment the eating disorder completely resolved but was replaced by a series of very dangerous accidents that occurred each time she was betrayed and disappointed by a boy friend. This went on pari passu with a deepening understanding of her childhood and her psychodynamics but the middle of the therapy was very stormy and required tenacious efforts to maintain the treatment. The self-destructive behavior was traced to early and profound childhood disappointments and a sense that these were her fault because she was so unlovable and therefore deserved punishment. A dangerous stalemate developed in the treatment after a number of years. The analyst presented the case to colleagues several times and wrote it up in detail, which enabled him to understand his own countertransference and resolve it. This resulted in a dramatic change in the patient and a very favorable and happy ending to this very difficult treatment after 15 years. Although the author believes all patients in psychoanalysis should be approached with as neutral and objective a stance as possible, emphasizing free association and dream material in order to interpret the crucial childhood determinants of the patient's psychopathology, in cases such as psychotic character disorders the outcome clearly also depends on interpersonal factors. The case illustrates the deep partly conscious and partly unconscious interaction between a patient and her analyst over many years of treatment and the profound effect this has on the outcome. It underscores the importance of patients being allowed to heal in their own way and in their own time without intrusion or interference from the analyst. It also demonstrates the crucial importance of long-term psychoanalytic therapy as a life-saving procedure in cases where it is appropriate in spite of the great amount of time and expense involved.

Self-Analysis and Post-Termination Improvement After Psychoanalysis and Long-Term Psychotherapy

Long-term follow-up studies of long-term psychoanalytically oriented psychotherapy or psychoanalysis are extremely rare, and few have focused on the post-treatment process itself. In the Stockholm Outcome of Psychoanalysis and Psychotherapy project, one of the results was that patients in psychoanalysis continued to improve after termination to a higher degree than patients in long-term psychotherapy. In this study 20 patients selected from the project were interviewed on two occasions, one and two years after termination, in order to explore how they described their post-treatment processes. The interviews were studied qualitatively using a multiple case study design, and categories of different types of post-treatment development were created from these case studies. Results indicate that the variation within treatment groups is large, and that development may continue in several ways after termination. The most striking difference between psychoanalysis and psychotherapy was not, as hypothesized, in the self-analytic function, but in various self-supporting strategies described by former analysands but not by former psychotherapy patients. However, only self-analysis was significantly correlated with post-termination improvement across both treatments. Three patients improving after termination and three deteriorating are described in detail as illustrations. Some methodological constraints of the design limit the generalizeability of results.

On Men Crying: Lear's Agony

King Lear vowed that because he was a man he would rather go mad or die than weep. Many adult male patients in psychoanalysis have just such an internal prohibition against crying, learned individually and often culturally encouraged, a prohibition that affects their ability to process loss, maintain intimacy, and accept vulnerability. It is suggested that the appropriate psychoanalytic role with these patients is to recognize and actively address this culturally supported prohibition. In addition, it is proposed that the prohibition against men crying may be a consequence of male envy of maternal traits and other feminine characteristics. Further, it is suggested that the developmental theory that the male child must "disidentify" with the mother memorializes a phallicism that often invokes the prohibition against crying in men and is itself mistaken.

Transference and relationship: Technical Implications in the psychoanalytic process with a borderline patient

This paper reviews how the bond between the therapeutic relationship and transference is created, illustrates its technical management, and provides a basic methodology for the exploration of both transference and the therapeutic relationship. For this purpose, the current therapeutic relationship, the concept of affective dominance, the object relation triggered by transference, the past and present unconscious, and the relationship pattern (CCRT) applied to dreams will all be considered. The approach in this paper is based on an object relation conceptualization. Highlights of the theory underlying the technique will be illustrated in a succinct discussion of the clinical treatment of a borderline patient in psychoanalysis.

Psychoanalysis and Its Discontents.

There are only 5,000 patients in psychoanalysis with members of the American Psychoanalytic Association (APsaA), and these analysts are often viewed as arrogant and insular. As a laboratory for psychoanalytic institutions the APsaA provides crucial lessons for the future across the field. What ingredients are needed for psychoanalysis to be a vibrant discipline? What factors have prevailed where psychoanalysis is successful? The author explores the cases of Argentina and France, where psychoanalysis is relatively popular, and then returns to the U.S. situation. Insular mind-sets led to many missed opportunities for cultural and academic engagement in the United States. As an example, the author explores responses to the making of John Huston's film Freud: The Secret Passion. To become revitalized, psychoanalysis needs to be a cultural asset. Psychoanalysts need to build bridges, engage in partnerships, and emphasize the exciting method of philosophical probing of the human mind and the nature of human nature.

Analyst Discovers Lessons In Harry Potter’s Ordeal

Back to table of contents Previous article Next article Clinical & Research NewsFull AccessAnalyst Discovers Lessons In Harry Potter’s OrdealJoan Arehart-TreichelJoan Arehart-TreichelSearch for more papers by this authorPublished Online:1 Mar 2002https://doi.org/10.1176/pn.37.5.0033Who is Harry Potter, the young hero of J.K. Rowling’s books and now the latest darling of moviedom? Laurie Pahel-Short, M.D., a Chapel Hill, N.C., psychiatrist and candidate at the University of North Carolina-Duke Psychoanalytic Education Program, decided to put Harry “on the couch” to find out.As she reported at the December meeting of the American Psychoanalytic Association, Harry is a boy wizard, yes, but also much more—a boy who was abused by his caretakers, yet who finds recovery through kind teachers and hard work and by facing fearsome challenges. All of these factors contribute to his appeal, she believes.But what is especially interesting about Harry Potter from a psychoanalytic point of view, she noted, is that there are striking parallels between Harry’s painful childhood and those experienced by a number of patients in psychoanalysis, as well as between Harry’s reformation and patients’ recovery in analysis. Here are some examples.When the Harry Potter series starts out, Harry is experiencing a rough childhood. His caretakers, the sadistic Dursleys, make him live in a dark cupboard, ignore him on a daily basis, forget all of his birthdays, withhold food from him, and isolate him for prolonged periods as punishment. Such childhood abuse, of course, also occurs in the real world.In spite of the abuse that he experiences, Harry draws upon innate psychological strengths to survive. In the real world, some people who experience similar torments also find the strength to survive.Harry finally has a chance to escape from child abuse—by going to wizard school. Yet deciding to leave the Dursleys requires courage on his part because he doesn’t know what he’ll find at the school. Or as Pahel-Short put it: “It requires extraordinary courage to forego what’s familiar, even when it’s abuse, for the unknown.”Along the same lines, when people who experienced child abuse decide to enter analysis to recover from that abuse, they also exhibit courage. “Patients cannot predict what awaits them as a consequence of treatment,” Pahel-Short said.Even after Harry decides to go to wizard school, he almost doesn’t make it because of sabotage by the Dursleys. In a similar vein, some patients who decide to pursue analysis because of childhood trauma sometimes almost don’t make it because of obstacles placed in their way by family members.Once Harry enters wizard school, he has contact with Professor Dumbledore, an all-knowing, all-powerful, paternal figure. Dumbledore resembles the analyst for the person entering analysis.Harry shows an unwavering trust in the professor’s goodness and power. Similarly, patients with a history of abuse will engage in treatment only if they believe that an analyst is trustworthy.Now that Harry has entered wizard school, he must start rebuilding his life. Similarly, once a patient who was traumatized in childhood starts analysis, he must begin the hard work of discovery and reconstruction.Lord Voldemort personifies evil in Harry’s world. He will not die and reappears in different, vaguely recognizable forms. Similarly, when a person enters analysis in hopes of coming to terms with bad childhood experiences, he or she must deal with unconscious, painful childhood memories that will not die.Harry learns to recognize signs of Voldemort’s reappearance—say, through dreams. Along the same lines, a patient in analysis uses dreams to recognize unconscious painful memories.Just as Harry seeks the help of Dumbledore in dealing with Voldemort, so the patient in analysis seeks the help of the analyst in dealing with unconscious, painful memories.Fantastic feasts at wizard school and tasty care packages from the mother of another student help compensate for the nutritional deprivation Harry experienced while living with the Dursleys. Similarly, Pahel-Short pointed out, “the patient may experience enough sustenance in psychoanalytic treatment to begin to acknowledge and to recover from a past tainted by insidious cruelty.”In every Harry Potter book, Harry encounters a daunting ordeal, yet prevails. One reason he prevails is because he is in the safe confines of the wizard school. Patients in analysis also need to feel that they are secure if they are to make progress.Nonetheless, the wizard-school environment defies clear definition and changes as the needs of its inhabitants change. Similarly, Pahel-Short explained, “The analytic holding environment must evolve with the individual course of a patient’s treatment. . . .A more complex structure develops as characteristics of the therapeutic dyad become increasingly nuanced.”All in all, Pahel-Short concluded, “Harry Potter’s story serves as a useful metaphor for childhood abuse and neglect and for recovery through psychoanalytic treatment. The psychoanalytic sojourn can be as exciting, mysterious, and arduous as Harry Potter’s transformation at Hogwarts’ School of Witchcraft and Wizardry.” ▪ ISSUES NewArchived

The older patient in psychoanalysis.

The demographic shift toward extended longevity has led to a commensurate increase in the length of the working and productive years, and with it an increase in the number of so-called "older" patients who come into psychoanalysis or psychoanalytic psychotherapy. This led the Psychoanalytic Research and Development Fund to support a four-year study by a small group of experienced psychoanalysts of "the older patient in psychoanalysis." Aging and old age are considered to be the final developmental crisis of the successive epigenetic phases of the life cycle. Eleven case presentations and various briefer clinical vignettes informed us that older and even old individuals, who seek treatment themselves or who are appropriately referred, respond in a positive and effective fashion to psychoanalysis and psychoanalytic psychotherapy. As do younger patients in analysis, such older people, motivated by the wish to make the most of what time is left, become interested in understanding their pasts with respect to the present and the future. The life stories of two older men who undertook analysis, and the courses and outcomes of their analyses, illustrate our findings and impressions. In both cases conflicts and difficulties from earlier developmental phases, extending back even as far as the oedipal and preoedipal years, were revived during their older years. And although these conflicts might have been beyond definitive resolution, what is salient is the extent to which they were ameliorated: sufficiently that they did not impede a satisfactory adaptive solution of the final crisis of the normative sequences of the life cycle.

Outcomes of Psychoanalytic Therapies

Using a naturalistic design, 44 patients in psychoanalysis were examined with regard to qualitative and quantitative outcome of therapy. The results were compared with those from 56 dynamic and 164 inpatient therapies. Comparison of symptoms, diagnoses, and motivation prior to therapy led to the conclusion that the patient groups treated within these settings differed greatly. For this reason randomisation appeared to be an inadequate strategy for comparing groups in different therapeutic settings. Using different outcome criteria, it could be demonstrated that psychoanalysis patients on the whole attained good therapeutic results. The outcomes were the best in comparison with the other two therapy categories investigated. The use of different outcome criteria and observer perspectives (patient and therapist) led to therapy results with clear-cut differences. In the patient view, the main effect was cessation of psychosomatic, anxiety- and depression-related symptoms. The therapists furthermore reported clear-cut changes in the scales depicting relationship variables. The study presents success rates obtained on the basis of different outcome criteria and discusses them with special emphasis on the methodology of recording outcomes. The paper concludes by making recommendations for psychoanalysis studies yet to be planned.

Characteristics of psychoanalytic patients under a nationalized health plan: DSM-III-R diagnoses, previous treatment, and childhood trauma

This article reports the results of a survey to collect data on the characteristics of patients in psychoanalysis under a nationalized health insurance scheme. A questionnaire, to be answered anonymously, was sent to all 174 accredited psychoanalysts in Ontario, Canada. Part 1 of the questionnaire consisted of 38 questions on the analyst's pattern of practice. Part 2, also to be filled out by the analyst, consisted of 452 questions on the demographic characteristics, childhood traumas, DSM-III-R diagnoses, and indications for psychoanalysis of each of the analyst's patients. One hundred seventeen analysts responded--a survey response rate of 67%--with data on 580 patients. Fifty-nine percent (N = 344) of patients were women, and 41% (N = 236) were men. Eighty-two percent had attempted other forms of treatment, including briefer forms of psychotherapy and medication, prior to psychoanalysis. During childhood, 23% had had traumatic separations, 23% had been sexually abused, 22% had been physically abused, and 21% had had a parent or sibling die. The mean number of adult psychiatric disorders at the beginning of analysis was four, and the mode was two. In a nationalized health insurance scheme, the psychoanalytic patients were mostly women, they had high rates of trauma and psychopathology, and they had attempted other forms of briefer treatment before resorting to psychoanalysis.

On A Type of Heterosexuality, and the Fluidity of Object Relations

This paper delineates a form of heterosexuality whose underlying psychological structure resembles that of perversions. It is characterized by: idealization of instinctual processes, whereby the ego subordinates the object to the actualization of the instinctual event itself; heightened narcissism in an otherwise neurotic ego organization; multiple intrapsychic uses of the object; a special kind of defensive organization; an experienced victory over the superego and associated elevation of certain aspects of the ego ideal; and a resultant alteration in the nature of close interpersonal relationships. I use clinical vignettes from both male and female patients in psychoanalysis to focus on the phenomena in question. The thinking of Chassequet-Smirgel, Freud, Khan, Rangell, Socarides, and others is used in an attempt to gain an encompassing perspective. It is emphasized that patients demonstrating this form of heterosexuality do not possess a perversion per se, but demonstrate a character neurosis which integrates certain perverse mechanisms into its defensive organization. These mechanisms can be isolated and studied in psychoanalytic treatment, with the potential for illuminating their defensive and mood-regulating functions, and eventual working through and resolution of the intrapsychic conflicts underlying them. Some comments on the implications of this form of sexuality for our contemporary culture are included.