Reactions of Outpatient Schizophrenics to Group Psychotherapy

Preoedipal patients present a special problem in group treatment. This is because their difficulties arose largely before they learned to use words. Such patients are prone to act. rather than talk. They do not respond well to interpretation. They must be approached and influenced through feelings. We can utilize the group to provide them with maturational experiences, helping them reach a more adult level of mental functioning so that our usual technical interventions can be brought into play. The paper discusses methods for enhancing this process, including reflection, emotional communication, using reconstruction to close developmental gaps, and immunization.     

The psychoanalytic paradox: the self as a transitional object

I have focused upon a group of patients whose biological needs for nurture and comfort were adequately met but whose mothers never related to them beyond simple caretaking. They never smiled at their children inasmuch as they derived no pleasure from playing with them or in their emerging sense of aliveness. From both the analyses of mothers and these patients, it appears that the mothers used their children as transitional objects. In turn, the children's emotional development became fixated in the in-between transition space. This fixation led to specific types of character structure and ego defects. Early development levels did not form a smooth continuum with higher later acquired adaptive ego states. There seem to be extensive lacunae in the middle layers of the psychic apparatus which manifested themselves as defective modulating elements. These patients showed extremes of behavior, marked polarities of sane, sensitive rationality to psychoticlike irrational episodes. There were no transitional gray areas between black and white. They exhibited a peculiar kind of fragmentation or splitting in which connecting bridges between higher and lower levels were missing. There are many such patients who seek treatment. However, they present special problems in therapy which can be explained in terms of the psychoanalytic paradox. The psychoanalytic paradox refers to a treatment impasse caused by an imbrication of psychopathology and various attributes of the psychoanalytic method. The mother's attitude toward her infant child has some similarity to the low-keyed objective analytic attitude, what has been sometimes referred to as analytic neutrality. These patients require different modes of relating which indicate that the therapist is, unlike the mother, very much concerned with their patient's developing autonomy and their entering and exploring the external world. These variations of analysis are not modifications or deviations of analysis. They are elements of the analytic process necessary for the treatment of specific types of psychopathology. Just as each patient is unique and the transference manifests itself in a particular fashion which then causes the analyst to make certain interpretations, the variations of technique discussed in this article address themselves to the construction of a holding environment appropriate for this group of patients.     

Can negative attitudes toward patients with borderline personality disorder be changed? The effect of attending a STEPPS workshop

We sought to determine whether negative attitudes toward patients with borderline personality disorder (BPD) can be modified through education. Mental health clinicians attended a 1-day workshop on the Systems Training for Emotional Predictability and Problem Solving (STEPPS) group treatment program for BPD. A questionnaire to assess attitudes towards BPD was given to 271 clinicians before and after the workshop. Following the workshop, clinicians endorsed having significantly greater empathy toward patients with BPD, and having greater awareness of the distress and low self-esteem associated with the disorder. Significant improvement was seen in the clinicians' attitudes toward patients with BPD and their desire to work with them. Clinicians were significantly less likely to express dislike for BPD patients. They also reported feeling more competent in their ability to treat these patients. The study offers preliminary evidence that negative attitudes toward patients with BPD can be modified through education.     

Emergent themes and roles in short-term loss groups

Clinical observations regarding themes and roles that are characteristic of short-term, psychoanalytically oriented therapy groups for loss patients are presented. They reflect aspects of both the therapy and the patients. Themes refer to the content of a recurrent conflict in the group. They include trust, survivor guilt, mortality, and termination. Roles refer to a set of patient behaviors that represent a shared conflict. They include the apparition, monk, professor, professional nurturer, emotional conductor, and cruise director. Challenges that the themes and roles present to the therapist and clinical guidelines for addressing them are offered. Awareness of characteristic themes and roles and possible therapist responses are regarded as important parts of the preparation and training of therapists who plan to conduct short-term loss groups.     

A treatment trial of an information package to help patients accept new dentures

Intolerance of dentures can be very distressing and difficult to treat. Therefore, 44 patients, having had partial or total dental clearance, completed the Brief Symptom (Psychiatric) Inventory, the Hospital Anxiety and Depression Scale and the Satisfaction with Life Scale. Allocated alternately, each patient had treatment as usual or watched a video containing information, recapitulated in a leaflet, based on the Self Regulatory Model of health beliefs explaining the experiences of wearing dentures and how to tolerate them. They were then fitted with dentures. Two and six weeks later, although both groups expressed favourable expectations of their dentures, the control group deteriorated continually on all measures, correlated with a decline in self-reported dental functioning. The video group improved on all measures except Satisfaction with Life. Therefore, our study is unique in showing that appropriate management of patients can arrest (1) clinically significant distress which can be occasioned by the replacement of teeth by dentures and (2) the development of complaints which may be seen as spurious. Experimental procedures are suggested to determine the influences which have brought this about in our study.     

The Class Method in the treatment of Psychotic Patients

Contrary to traditional thinking, a review of the recent literature has suggested that bipolar patients can be treated in homogeneous therapy groups in conjunction with concomitant lithium management. Important psychodynamic and interpersonal features are reviewed that have received empirical support and have enhanced our understanding of these patients. Goals for bipolar groups include educating patients on the nature of the disease, helping them learn ways of coping with its symptoms, and encouraging them to discuss relevant psychodynamic and interpersonal issues. To achieve these goals, therapists have used techniques involving education, support, and facilitation of group discussions. Further clinical and empirical work needs to be done to evaluate the effectiveness and process of these bipolar groups, particularly in the inpatient setting.     

糖尿病“达标”教育对控制2型糖尿病的影响

为评价"达标"教育对新诊断2型糖尿病(T2DM)监测及控制水平的影响,选取新诊断T2DM患者90例,随机分为两组,实验组进行"控制目标"认知教育,对照组不进行。治疗6个月后,比较两组控制水平。结果实验组与对照组相比,血糖、血压、体重监测及主动拜访专业医生的频次显著为高,血糖、血压、胆固醇控制显著为好。提示对新诊T2DM患者进行"达标"教育可提高DM监测频次及控制水平。     

驳《告别中医中药》

张功耀<告别中医中药>,在<医学与哲学>2006年第4期刊出前后,许多网站以"废除中医中药"为主题词,大肆传播,已是满城风雨.     

利多卡因凝胶在手术室麻醉诱导后留置尿管中的应用

分析手术室麻醉诱导后留置尿管产生尿路疼痛等不良反应的原因,探讨利多卡因凝胶在克服上述反应方面的作用及其他预防措施。采用方便取样将70例留置尿管的患者分为试验组和对照组,麻醉诱导后试验组在尿管上涂抹利多卡因凝胶（0．5ml／cm）后再按常规操作插管;对照组以石蜡油为润滑剂按常规操作留置尿管。比较两组患者心率、血压情况及躁动、疼痛评分。结果提示麻醉诱导后留置尿管可以有效减轻患者清醒状态下置管引起的尿路疼痛等问题,但不能避免患者苏醒期出现上述反应;使用利多卡因凝胶可有效预防患者苏醒期出现的尿路疼痛及其它不良反应,增加患者的舒适度。     

Social Change and the Development and Co-Optation of a Black Antisystemic Identity: The Case of Rastafarians in Jamaica

In this article I offer an overview of the social processes that helped to define the Rastafari as an antisystemic group and identity, and how they came to be celebrated as embodying a liberating ideology and a positive expression of Black identity, by people in Jamaica and throughout the world. The Rastafarians of Jamaica, from their emergence in 1931, were vocal critics of colonialism, imperialism, labor exploitation, discrimination, and class and race-based stratification. They melded their activism and social critique with a religious ideology that holds Ethiopian Emperor Haile Selassie to be the Christ returned. However, the Rastafari's views made them very unpopular among Jamaica's general populace. They were frequently punished because of their beliefs and practices. I provide an example of how historical legacies, social change, watersheds, and social institutions interact with the formation of group identity.     

Existential issues in group psychotherapy

Existential issues in group psychotherapy derive from existential thought both as a philosophy and as a value system. Its origins derive from the weakening of traditional values and the growing alienation of man from himself. The unique features of existentialism can be applied to all forms of therapy. These features are universal to humankind. They are finiteness, aloneness, guilt, responsibility, and freedom. In including existential concerns as part of group psychotherapy, therapist and patients move more closely to bilateral relationships and subjective interactions.     

A.G.P.A. News

Clinical observations regarding themes and roles that are characteristic of short-term, psychoanalytically oriented therapy groups for loss patients are presented. They reflect aspects of both the therapy and the patients. Themes refer to the content of a recurrent conflict in the group. They include trust, survivor guilt, mortality, and termination. Roles refer to a set of patient behaviors that represent a shared conflict. They include the apparition, monk, professor, professional nurturer, emotional conductor, and cruise director. Challenges that the themes and roles present to the therapist and clinical guidelines for addressing them are offered. Awareness of characteristic themes and roles and possible therapist responses are regarded as important parts of the preparation and training of therapists who plan to conduct short-term loss groups.     

Care versus treatment at the end of life for profoundly disabled persons

Individuals who are profoundly mentally handicapped do not have the capacity to make their own decisions and also do not have a past record of decisions, from when they had capacity, to guide us in making decisions for them. They represent a difficult group, ethically, for surrogate decision making. Here I propose some guidelines, distinguishing between these patients and patients in a persistent vegetative state (PVS). As the life span of patients becomes shorter, or their level of consciousness becomes permanently impaired, the presumption for comfort care should become an imperative, and the standard of evidence to justify any invasive intervention should become higher. For members of this population, who have no more ability to refuse treatment than to consent to it, protection of the vulnerable must mean allowing a peaceful death as well as a comfortable life. Reasonable legal safeguards are also proposed to allow improved end-of-life decisions to be made for this population.     

The Cultural Underpinnings of Subjectivity and Inter-Subjectivity: A Discussion of “Trump Cards and Klein Bottles: On the Collective of the Individual”

In “Trump Cards and Klein Bottles: On the Collective of the Individual,” Dr. González (this issue) argues for the centrality of dynamic and shifting group identifications in shaping our subjectivity and our inter-subjective linking from moment to moment. My commentary about this paper is organized around the themes of cultural dislocation and cultural displacement, experiences related to large-group identifications and identity. These constructs, cultural dislocation and displacement, can deepen our understanding of how inter/intra-group tensions (historic and current) can play a determinative role in shaping individual subjectivity and inter-subjective linking. They complement and amplify claims regarding the centrality of our group identifications on ego functions. They also point toward the determinative impact of context and clashing cultural systems on our object relations and unconscious fantasies. Studying the links between individuals, collectives, and the cultural systems that structure them will deepen our theories and extend our relevance.     

Craving,longing, denial,and the dangers of change: clinical manifestations of greed

Greed is the unrelenting and unrealistic search for all the good an object has to offer and, via identification, all the good one can produce and provide. In phantasy, and sometimes in the patient's early developmental environment, the object and the ego demand more from each other than either have to give. Some patients cannot contain their urge to possess all and to be all, so it becomes a part of the interpersonal and psychological relationship with the analyst rather quickly. These patients feel something is owed to them, and they demand to be fed immediately. Other patients try and hide these greedy phantasies by being the opposite of greedy. They strive to be independent and charitable, while having great conflict over deeper desires to be dependent and in possession of an idealized giving object, an all-providing breast. Case material was used to explore these ideas.     

Biparental failure in the childhood experiences of borderline patients

The purpose of this study was to assess the role of biparental abuse and neglect in the development of borderline personality disorder (BPD). A semistructured research interview was used to blindly assess the childhood experiences of biparental abuse and neglect reported by 358 borderline inpatients and 109 axis II controls. Eighty-four percent of borderline patients reported having experienced some type of biparental abuse or neglect before the age of 18; 55% reported a childhood history of biparental abuse; 77% reported a childhood history of biparental neglect. These experiences were also reported by a substantial percentage of Axis II controls (biparental abuse or neglect [61%], biparental abuse [31%], and biparental neglect [55%]). However, borderline patients were significantly more likely than axis II controls to report having been verbally, emotionally, and physically but not sexually abused by caretakers of both sexes. They were also significantly more likely than controls to report having caretakers of both sexes deny the validity of their thoughts and feelings, fail to provide them with needed protection, neglect their physical care, withdraw from them emotionally, and treat them inconsistently. It was also found that female borderlines who reported a previous history of neglect by a female caretaker and abuse by a male caretaker were at significantly higher risk for having been sexually abused by a noncaretaker. Taken together, the results of this study suggest that biparental failure may be a significant factor in the etiology of BPD. They also suggest that biparental failure may significantly increase a preborderline girl's risk of being sexually abused by someone other than her parents.     

家庭处境不利儿童的社会性发展研究述评

本文就家庭视角评述国外关于处境不利儿童的社会性发展有关研究。有关文献表明,处境不利儿童的自我概念有明显的外在化特征,区分性低,较少指向未来;他们存在社会信息加工中的译码困难和归因偏向,其信息加工技能和认知控制技能都存在一定的问题,社会性情绪发展也存在诸多困难;他们的亲子依恋往往是不安全甚至矛盾类型;他们往往难以被同伴所接纳,在交往中更多地表现出适应不良性行为,其友谊质量也比较差,但自我效能、自我调节以及良好的群体特征是改善其同伴交往的重要因素;家庭的各种不利因素还会对其社会交活动中的活动能力、活动数量、活动水平和活动技能带来影响,在他们身上也更容易出现攻击、退缩以及各种过错行为和违法犯罪行为。当前,有关这些儿童的神经生理与心理学结合的研究也正在进行之中。     

Die Praxis der Konzentrativen Bewegungstherapie (KBT)

In a survey the 458 members of the German Association for Concentrative Movement Therapy (DAKBT) were asked in a questionnaire, to answer the question how the actual therapeutic practice of Concentrative Movement Therapy (KBT) in Germany looks like. They were asked about their therapeutic setting, the patients diagnoses and the duration of treatment. 67.5% of the questionnaires were sent back. 191 of those who answered, are working as professional psychotherapists, 62.8% of them with out-patients, 51.3% in hospitals, 17.8% in both therapeutic fields. Besides group psychotherapy most of them offer individual therapy, especially with out-patients. It is shown, that besides psychosomatic disorders (being a wellknown indication) KBT is also applied in a broad variety of other psychic disorders. Half of the outpatient treatments is finished within 50 meetings. Female patients and patients with personality or eating disorders show up a greater number of contacts in out-patient individual treatment. The results verify that in practice KBT is no longer confined to a supplementary group therapy.     

Intrusive thoughts and auditory hallucinations: a comparative study of intrusions in psychosis

Several theories of auditory hallucinations implicate the involvement of intrusive thoughts and other theories suggest that the interpretation of voices determines the distress associated with them. This study tested the hypotheses that patients who experience auditory hallucinations will experience more intrusive thoughts and be more distressed by them and interpret them as more uncontrollable and unacceptable than the control groups. It also examines whether the interpretation of hallucinations is associated with the distress caused by them and whether there are differences in the way that patients respond to and interpret their thoughts and voices. A questionnaire examining the frequency of intrusive thoughts and the reactions to them was administered to a group of patients with a diagnosis of schizophrenia who experienced auditory hallucinations, a psychiatric control group and a non-patient control group. In addition, the patients in the first group completed a similar questionnaire in relation to their voices. Analyses of covariance showed that patients who experienced auditory hallucinations had more intrusive thoughts than the control groups and that they found their intrusive thoughts more distressing, uncontrollable and unacceptable than the control groups. Correlational analyses revealed that patients' interpretations of their voices were associated with the measures of distress in relation to them. Repeated measures analyses of covariance found no differences between thoughts and voices on the dimensions assessed. The theoretical and clinical implications of these findings are discussed.