On the origins of contemporary structural theory: an appreciation of "Ego Psychology and the Problem of Adaptation"

Hartmann's monograph was one of four works which produced a major revision of psychoanalytic theory. Following a brief summary of the monograph, this essay assesses its impact on contemporary psychoanalytic thinking. It considers some confusions about and revisions of Hartmann's ideas and explores terrain first broached in this work which has become very influential but which has not yet been fully exploited. Lastly, this essay will consider Hartmann's hope that psychoanalysis would become a general psychology.     

The contribution of Hartmann's adaptational theory to psychoanalysis, with special reference to regression and symptom formation

My experience of clinical work is consistent with the conclusion that both practice and theory are improved by applying the contributions of Heinz Hartmann. His work provides an important conceptual bridge to understanding the adaptive and pathologic changes that appear in the course of human development. The specific details of those changes are just as much an issue demanding the analyst's attention as is the tracing of patterns of childhood instinctual life. In this paper, I will point to some areas of controversy where renewed attention to Hartmann's ideas might be useful, and I will attempt to illustrate the clinical utility of his theoretical contributions.     

Hartmann's "Ego Psychology and the Problem of Adaptation"

Hartmann's monograph is an argument for the problem-solving value of all aspects of the mind and for the subordination of intelligence to the organism's larger, primarily social purposes. Hartmann proposed that, in psychoanalytic treatment, intelligent reflection serves one's largest purposes by taking respectful account of non-rational but adaptive ways of appraising reality, with a view toward making the best use of non-rational as well as rational propensities. He regarded it as the kind of thinking that the sociologist, Karl Mannheim, had recommended to government planners faced with immensely complicated, incompletely masterable forces. Hartmann's view of the role of the intellect in analytic treatment suggests that therapists should maintain both their demand for intelligent reflection and their hopefulness about other kinds of work that may be going on sub rosa.     

"Lesbians, gay men, and their parents": a critique of LaSala and the prevailing clinical "wisdom"

This article challenges the popular assumption that coming out to family of origin is important for lesbians and gay men's mental health and couple relationships. First, I present theory emphasizing the unique position of lesbians/gays in families of origin and the significance of "families of choice." Second, I review the quantitative research on social support received by lesbians/gays from family of origin, friends, and other social network sources. Third, I demonstrate how the dominant clinical opinion about coming out to family is based on an unwarranted use of theory developed for heterosexuals and on overgeneralization of findings from studies of white, upper-middle-class, North American lesbians/gays. Fourth, I propose five determinants of lesbian/gay persons' decisions to come out to family-of-origin members. Fifth, I argue that such decisions are constrained by "realistic" costs/benefits in various sociocultural niches rather than being a simple function of individuals' levels of differentiation. Lastly, I offer an expanded contextual stance for the family therapist working with lesbian/gay clients.     

Reconstruing the "reconstruction" of psychopathy: a comment on Cooke, Michie, Hart, and Clark

In this comment we highlight critical problems in the estimation of parameters for their hierarchical three-factor model of psychopathy, as assessed with the Hare Psychopathy Checklist, and their interpretation of these factors as causally related to socially deviant behavior. We argue that there is nothing "causal" about a model in which cross-sectional data are used to assert that antisocial tendencies are consequences of other more fundamental psychopathic traits. We present an equally viable model, based on the PCL-R four-factor solution, in which antisocial tendencies play a fundamental role in the construct of psychopathy, consistent with previous research and clinical tradition.     

Mahler's concepts of "symbiosis" and separation-individuation: revisited, reevaluated, refined

Mahler's developmental theories are reviewed in the light of subsequent clinical experience and theoretical and empirical critique. Several modifications are proposed, each tending to particularize and focus the nature and scope of developmental events. Particular attention is accorded the "symbiosis" concept, and focus placed on transmission of psychodynamic issues from mother to infant and on the progressive buildup of self-sustaining pathological systems. Overall, an argument is advanced for the continued developmental import of Mahler's "symbiotic" and "separation-individuation" phase formulations, though with recognition of significant individual differences in their role in individual lives. An argument is advanced also for the clinical utility of these ideas, and illustrations presented, though the link between clinical applications and psychoanalytic theories of early development remains problematic.     

生命伦理与制度伦理冲突的终结--"非典"事件的伦理学审读

SARS事件可以为生命伦理与制度伦理历史冲突的终结提供佐证;公民享有的健康权必须平等。应大力矫正医疗与预防的关系,必须重视发展公共卫生事业;应重新思考中国的卫生事业改革,中国医疗改革不能实行市场化,卫生经济伦理学的研究证明,中国的卫生制度改革重点在农村,“适者生存”的原则不适用于卫生事业。创构灾疫伦理学是生命伦理学的一项使命。     

健全社区卫生服务功能与防控"非典"传播的理性思考

针对我国当访“非典”防治工作的严竣形势,对健全社区卫生服务“六位一体”功能与防控“非典”传播问题进行哲学思考,着重在健全社区卫生服务功能是防控“非典”传播的客观要求;社区卫生服务功能不全将会对防控“非典”工作产生不利影响;构筑防控“非典”传播的有效机制和基础防线,必须健全社区卫生服务功能等方面作了分析论述。     

"An analysis-of-variance model for intrasubject replicaiton design": some additional comments

The fixed effects ANOVA procedure utilized by Gentile, Roden, and Klein (1972) for single subjects is found inappropriate. Hartmann's proposal of a one-way fixed-effect ANOVA model is also considered. Time series analysis that takes serial correlation effects into account is recommended.     

Hartmann on adaptation: an incomparable or incomprehensible legacy?

Hartmann's essay sets forth ideas of incomparable value as well as incomprehensible density. While he developed many important concepts which have far-ranging clinical utility even today, his attempt to extend psychoanalysis into a general psychology back-fired because it separated psychoanalytic concepts from analytic data. Because of his lack of clinical material or anecdotal illustration, Hartmann's theoretical scaffolding has been frequently misunderstood and misapplied. This paper re-examines Hartmann's essay in light of current clinical and metapsychological issues, and illustrates some of his more important ideas.     

Pediatric Health-Related Quality-of-Life Measurement Technology: Intersections between Science, Managed Care, and Clinical Care

The demand for health care outcomes assessment is increasing, driven by the proliferation of managed care as a form of health care financing. Providers, consumers, and payers can use health care outcomes to improve the efficiency and quality of care, spur performance improvement, and demonstrate accountability. This review introduces health outcomes and focuses on one particular outcome—pediatric health-related quality of life (HRQOL), exemplified by the PedsQL, a brief, practical, reliable, valid, and responsive measure of pediatric HRQOL. HRQOL measurement has the potential, in pediatric clinical practice, to improve assessment, clinical management, and treatment evaluation if practical, conceptual, and empirical challenges are addressed. These issues are discussed and directions for future research are described that would demonstrate the value of HRQOL measurement in pediatric clinical settings.     

"Show me" bioethics and politics

Missouri, the "Show Me State," has become the epicenter of several important national public policy debates, including abortion rights, the right to choose and refuse medical treatment, and, most recently, early stem cell research. In this environment, the Center for Practical Bioethics (formerly, Midwest Bioethics Center) emerged and grew. The Center's role in these "cultural wars" is not to advocate for a particular position but to provide well researched and objective information, perspective, and advocacy for the ethical justification of policy positions; and to serve as a neutral convener and provider of a public forum for discussion. In this article, the Center's work on early stem cell research is a case study through which to argue that not only the Center, but also the field of bioethics has a critical role in the politics of public health policy.     

An intervention study of the effects of the coping strategy of "finding positive meaning" on positive affect and health

Previous research has shown that positive affect (PA) is associated with the coping strategies of "searching for and finding positive meaning." The purpose of this study was to investigate the relationship between the coping strategy of "finding positive meaning" and PA using an intervention method. Additionally, inasmuch as previous research has revealed that PA is associated with physical and mental health status, the current study measured health status in order to carry out a preliminary test as to whether PA increased by the intervention can also improve health. Participants in the intervention group (Japanese graduate students; 13 men and 16 women) reported the most stressful event during the past 3 days and its positive meaning, while those in the control group (13 men and 15 women) reported the most stressful event alone. Both groups reported twice a week for 5 successive weeks using e-mails. Three questionnaires, the Japanese version of the Positive and Negative Affect Schedule scales for measuring positive and negative affects (NA), the situational version of the General Coping Questionnaire for coping strategies, and the Japanese version of the General Health Questionnaire for health status, were administered to all participants just before the start of the intervention, after the conclusion of the intervention, and at the 5-week follow-up session. Results revealed that the "finding positive meaning" coping strategy and PA were enhanced by the intervention in the follow-up for men and women with no changes in NA. For the health scales of the General Health Questionnaire, no significant group-related effects were observed. Thus, the intervention had no significant influence on NA or health status. Implications of these findings for future research are discussed along with a few limitations in this study.     

National Identity,Instrumental Identifications,and the Caribbean's Culture of "Play"

The ability of West Indians to have multiple identifications, "to play the field" yet sustain a strong personal, participatory national identity shows that in their own way they have achieved freedom of the human condition. And, not trivially, this freedom is a double-edged sword. On the positive side, it reverts to their personal benefits and through that to real benefits to their islands. Evidence of such benefits are the steady flow of remittances and the money-spending tourism to the "home" country. On the negative side is the continued insularity and parochialism that prevents broader alliances of an enduring political type. Although good at coalescing for specific tactical and strategic ends, each island remains a "nation." The hope for a "West Indian nation" is as remote as it ever was.     

Worry, anxiety, and preferred length of sleep

Sixty-three female and 43 male undergraduates responded to a "worry" scale, a trait anxiety measure, and a question asking preferred length of sleep to clarify conflicting findings regarding the relationship between worry and anxiety and length of sleep (e.g., Hartmann, 1973; Hicks & Pellegrini, 1977; Kumar & Vaidya, 1984). Worry and length of sleep were positively correlated, supporting Hartmann's contentions. Anxiety was related to sleep in a U-shaped curvilinear fashion. Anxiety and worry were substantially correlated (r = .60) for subjects above the median on worry but were not correlated for subjects below the median. Worry may be the underlying construct in the positive relationship between anxiety and length of sleep for highly anxious persons. Comparison of high worry-low anxiety and low worry-high anxiety groups also suggests that our understanding of the relationships among sleep, anxiety, and worry may benefit from the simultaneous consideration of worry and anxiety factors.     

"Totem and Taboo" in a latency boy.

Against the background of Freud's "Totem and Taboo" the case of a seven-year-old boy is discusses, focusing on his identification with a cat. Guided by Freud's dialectic thinking and his discussion of the phenomena of patriarchy and matriarchy, one is led to contemplate the totemism of a matriarchally oriented boy. The attempt to understand this child's pathology is based upon the concept of the specificity of a developmental phase. In the light of anthropological data, clinical phenomena are evaluated ontogenetically, in analogy with the recapitulation hypothesis.     

Online "predators" and their victims: myths, realities, and implications for prevention and treatment

The publicity about online "predators" who prey on naive children using trickery and violence is largely inaccurate. Internet sex crimes involving adults and juveniles more often fit a model of statutory rape--adult offenders who meet, develop relationships with, and openly seduce underage teenagers--than a model of forcible sexual assault or pedophilic child molesting. This is a serious problem, but one that requires approaches different from those in current prevention messages emphasizing parental control and the dangers of divulging personal information. Developmentally appropriate prevention strategies that target youths directly and acknowledge normal adolescent interests in romance and sex are needed. These should provide younger adolescents with awareness and avoidance skills while educating older youths about the pitfalls of sexual relationships with adults and their criminal nature. Particular attention should be paid to higher risk youths, including those with histories of sexual abuse, sexual orientation concerns, and patterns of off- and online risk taking. Mental health practitioners need information about the dynamics of this problem and the characteristics of victims and offenders because they are likely to encounter related issues in a variety of contexts.     

胃肠肿瘤过度治疗的成因与对策

尽管现代胃肠肿瘤的治疗效果得到了极大的提高,但过度治疗现象仍普遍存在。临床医生缺乏整体观念,过度关注“瘤体”本身;医患双方“宁左勿右”的心理现象以及经济利益驱动是过度治疗存在的根本原因。外科手术和综合治疗的过度化导致医疗资源的浪费和患者生活质量低下。只有以循证医学的原则指导和规范肿瘤治疗;建立正确的临床决策分析模式;更新观念,坚持个体化综合治疗;加强综合治理,才能使胃肠肿瘤治疗走上健康发展的道路。     

"Factor analyses of the family assessment device," by Ridenour, Daley, & Reich

Ridenour, Daley, and Reich conducted a series of factor analyses using the correlational matrix of the subscale scores of the Family Assessment Device (FAD), published in Family Process, December, 1999. They conclude that "the FAD subscales be reorganized from their current seven-subscale format" (p. 507). We propose that this suggestion for reorganization is premature and based on the inappropriate application of an "internal consistency" model of scale construction to the FAD. We further suggest that the most important criteria regarding an assessment instrument are those of reliability, validity, and clinical utility. In the absence of this kind of data regarding alternative organizations of the FAD, we believe that the original subscales remain the best choice.     

Lao buddhism,mental health,and contemporary implications

Summary In the absence of mental health workers, the people of Laos effectively support one another through crises and role changes. They accomplish this by employing social institutions and traditions that have been present in their culture from antiquity. Central to these traditional social resources are religious ritual (especially thebaci), community elders, and homecentered religious activities involving the extended family, neighbors, and friends.We in the Western world can learn from Lao Buddhism. As mental health workers have displaced religious leaders, our standards for behavior have moved from what is right toward what is done. Life-change events have increased in our lives, butrites de passage have atrophied. At times of crisis, neighbors, relatives, friends, and clergy often fail to lend support when it is most needed.Religion can and should contribute to the mental health of a people. It cannot accomplish this by larger churches, more elaborate theology, or an isolated clergy. Instead, simple home-centered ritual, conducted by leaders whom participants know and with whom they can identify, should be adapted to the crises and role shifts in our lives today.with current clinical assignment as Director of Acute Inpatient Service and Outpatient Evaluation in the University's Day Hospital. In 1965–67, he served as Deputy Chief, Division of Public Health, Agency for International Development, Laos. He has written a number of articles on anthropology relating to the Meo of Laos and the Chippewa of Minnesota, drug abuse, and other psychosocial, medical, and public health topics.