Writing about patients III: Comparisons of attitudes and practices of analysts residing outside and within the USA

When analysts write about patients, they find themselves in a position of conflict. Their first loyalty is to their patients and maintaining confidentiality. However, they are also committed to advancing scientific knowledge in the psychoanalytic field. The attitudes and practices of 36 analysts residing outside the USA, who published articles using clinical material from their patients, are reported. Their attitudes and practices are compared with those of 30 author-analysts residing within the USA, who had been previously interviewed. Among the 66 analysts, geographic region was not a basis for distinguishing differences in attitudes or practices. Slightly more than twice as many analysts use only disguised material as regularly ask permission of their patients to write about them. The decision to use only disguise is somewhat more frequent for analysts who reside outside the USA than for those living within it. Analysts around the world are increasingly concerned about the accessibility of published material. More analysts have come to believe that it is necessary to ask permission before publishing material. Some analysts also believe that the request itself, and the patients reading written material about themselves, focus issues that are central to patients' characters and confl icts that can then be explored analytically.     

Writing about patients: IV. patients' reactions to reading about themselves

When analysands read about themselves in reports, their reactions range from anger, disappointment, or condemnation to a sense of appreciation or even idealization of the analyst. The eleven interviews reported here reflect only conscious responses; the unconscious layers were not probed for. It should be kept in mind also that the analysts of these patients might report very different stories. Other limitations are the small sample size and the representation only of patients who volunteered. Nonetheless, the information they provide may help analysts consider how and when writing about patients may influence their representation of themselves, the analyst, and analysis itself.     

Writing about patients: I. Ways of protecting confidentiality and analysts' conflicts over choice of method

Thirty American psychoanalysts who have published articles using clinical material from their patients were interviewed about their method for ensuring confidentiality. Almost twice as many analysts chose to disguise material as regularly requested permission for the use of patients' material. The other analysts in the sample varied their approach, depending on circumstances, between using disguise alone and using disguise but also requesting consent. Methods of disguise, the timing of request for permission in relation to the phase of analysis, and changes in analysts' ideas about the benefits and detrimental effects of these choices are discussed and illustrated. Each decision is reconsidered in light of its potential effect on patients and their analysis. The dilemma posed by the importance of writing about patients for the health and growth of psychoanalysis as a field and the potential negative consequences for patients and their analyses is considered.     

Juggling roles and expectations: dilemmas faced by women talking to relatives about cancer and genetic testing

Health professionals do not inform their patients’ kin about BRCA1/2 test results or genetic testing without their written consent. Thus, the onus is on women attending genetic counselling to talk to relatives about the family history and their potential increased risk. This communication process within the family is largely unexplored and provides the focus of the present study. Fifteen healthy women attending a genetics clinic for predictive testing were interviewed prior to receiving their test result and again 6 months later. A grounded theory approach was used. Findings illustrate the dilemmas women faced in juggling social roles and expectations, which had an impact on communication within the family in the context of predictive genetic testing. Tensions between responsibilities towards themselves and others and their fulfilment of social roles had an impact on who women informed and on how they did so. These factors should be considered when assigning patients the role of information provider.     

纸质与视频补充材料对手术知情同意体验的影响：以腹腔镜胆囊切除手术为例

知情同意书在医患沟通中起着间接传递信息的重要作用。以159名大学生为被试,通过操纵不同的知情同意方式,考察了纸质或视频补充信息对患者知情同意满意度、理解程度以及患者信息需求的满足程度影响。结果发现,接受纸质补充知情同意或视频补充知情同意的被试对知情同意过程的满意度、对手术信息的理解程度与知情同意信息需求的满足程度显著高于接受普通知情同意的被试。同时,纸质补充知情同意使得“治疗信息需求的满足程度”最高。这表明,纸质补充知情同意更能满足患者对治疗信息的需求。     

Patients reading about themselves: a stimulus to psychoanalytic work

Patients' reading of their psychoanalysts' papers about them as a vehicle for psychoanalytic work is a relatively new phenomenon in the field. Over the past five years, reports of analysts' employment of their writing in this fashion have begun to appear in the analytic literature. This paper presents clinical illustrations of this specific use of analysts' writing. These illustrations were drawn from interviews with analysts who published clinical articles in Psychoanalytic Dialogues between 1995 and 2003. The author considers some of the clinical and scientific implications of this use of papers written for publication.     

Do Written Reports of Suicide Induce High-School Students to Believe that Suicidal Contagion Will Occur?1

To see if high-school students who read that a distressed adolescent knew about suicide thought that suicidal contagion would occur, 66 consenting high-school students read a written account of John, a high-schooler with multiple problems including knowing someone who had died (either by suicide or viral illness). They then anonymously completed the UCLA Loneliness scale and a questionnaire about what John (or they in the same situation) might do. When John knew of a sympathetic response to a viral illness death, or an unsympathetic response to suicide, he was rated as relatively more likely to make new friends and less likely to want to die. These high school students saw themselves as immune to suicidal contagion from a written report, but thought that others might be vulnerable if people were sympathetic.     

Why we need to write openly about our clinical cases

To learn more about what is and is not effective in the psychoanalytic situation, analysts need to develop a library of detailed analytic case material. Open case writing, by not overconstraining readers, allows them enough access to the analytic couple's affective experience to persuade them of the authenticity and validity of the analyst-author's views. They are then free to rethink the material creatively on their own, to use it as they need to, and to learn from others, in order to enhance their analytic skills. Closed case writing hinders readers' creative freedom to understand and interpret, and hence to learn. To encourage analyst-authors to share their affective experiences in the analytic situation more openly, analysts need to establish a constructively collaborative attitude toward playing with clinical material. They need to take for granted that new readers, even authors themselves newly rereading their work, will discover something new. A dialectical process can then be established in which clinical authors and readers contribute to each other in an ongoing imaginative interchange.     

Informed consent as a prescription calling for debate between analysts and researchers(1)

This article is a review of the international scientific literature on informed consent and its use in some of the constituent organizations of the International Psychoanalytical Association (IPA). Because psychoanalysis comprises a theory based on practice, the dearth of clinical material for study, training and research purposes is a serious problem for analysts. Supervisions, presentations at scientific societies and congresses, publications and teaching material involve patients to an extent that goes beyond the work done in their sessions. Should consent be requested in these cases? This contribution addresses controversial and long‐standing issues such as informed consent and confidentiality, audio recording of treatments, knowledge production, the ambivalence of participating subjects over time and the perspective of analysts and patients respectively. The authors consider the various alternative approaches available for the handling of these ethical dilemmas without losing sight of the patient’s dignity and personal rights, while also taking account of the position of the analyst.     

A renaissance for Freud's Papers on Technique

The analyst depicted in Freud's Papers on Technique (1911-1915) struggles to split the patient's stubborn desire by reframing it as memory. In contrast, after the structural theory was adopted, analysts could picture themselves as liberating rather than struggling with patients, since their design was to show that the patient's fears are unrealistic. But North American analysts have come to doubt their ability to rule on what is and isn't realistic. They thus find themselves again struggling with stubborn desires, not just easing fears. Their solution has been to emphasize--and thus detach from--enactments. These analysts would seem to be even more in need of the old ideals of procedure than were "classical" analysts, who thought they could use "reality" as a standard.     

Attitudes about memory dampening drugs depend on context and country

When people take drugs such as propranolol in response to trauma, it may dampen their bad memories – tempering recall of a traumatic event. We examined people's attitudes toward these drugs. Americans and New Zealanders read about a hypothetical assault inserting themselves into a scenario as a victim attacked while serving on a peace keeping mission (soldier role) or while walking home from a job as a restaurant manager (civilian role). Then they told us whether they should receive a memory dampening drug, and whether they would want to take a memory dampening drug. Subjects were negatively disposed towards a memory dampening drug, but Americans who adopted the soldier role were more in favor of having access to the drug than those who adopted the civilian role. We discuss the implications of these findings in relation to an increasing trend in ‘cosmetic neurology’, medicating with the goal of enhancement, rather than therapy. Copyright © 2010 John Wiley & Sons, Ltd.     

Further reflections on the impact of clinical writing on patients

Though it is unlikely that instituting universal guidelines will ever be possible for patient approval of the analyst's use of clinical material outside of the treatment setting, the author offers some supplementary refl ections to those already available in the literature. Broadly applied informed consent guidelines would increase the distortion that already exists in our clinical literature due to self-imposed restraints by writers. Moreover, the powerful irrational forces mobilized by consent in the dyad are not easily 'held' by traditional applicable legal categories. Metapsychological formulations of the intrapsychic and intersubjective impact of patient participation in the writing process on individual analytic dyads are needed. Notions of privacy protection, validation, dyadic co-construction, or writing-as-containment by a third as rationales for informed consent fail to encompass the transindividual and external sources of human identity and the ineradicable lack of unity in the unconscious. Nevertheless, theoretical affi nity and preferred technique may be mediating factors in positive outcomes of the consent process. Some paradigms not only accommodate more comfortably but also actively seek the intersubjective repercussions of informed consent. Asanalternativeorcomplementaryviewpoint, theauthoroffersthehypothesis that the clinical ramifi cations of either disguise or consent are not exclusively, nor even necessarily, concerned with what patients read about themselves, but what they assess or intuit-directly or indirectly through the material presented-of their analyst's unconscious strivings. To truly triangulate the clinical reporting project, it is wisest to consult the third ear of a colleague to assess the potential impact on patients on what might be being unconsciously transmitted by the analyst in the writing and the consent process     

Fifteen minute stories about training

This panel presentation at the Journal's conference in St Petersburg responded to the conference theme of 'Ancestors in Personal, Professional and Social History' by relating it to the experience of training and being trained on the IAAP 'router' programme in Russia. The two organizers of the programme (JW and CC) have worked in Russia for over 12 years, bringing analysts from Britain to Moscow and St Petersburg on a 'shuttle' basis as supervisors and personal analysts. A few months after handing over the router programme in December 2010 to the Russian colleagues they had trained, they invited four analysts, three Russian and one Belarusian, to tell a short personal story about their training, linking it to the theme of 'the Ancestors'. The resulting four stories are very different but complement each other, using imagery to illustrate issues concerning both value and ambivalence. JW and CC jointly wrote their story about the programme in response to the four stories, reflecting on some of their themes and from them, giving consideration to the flexibility and limits of such a model of cross-cultural training. Themes in the stories included the possibility of mutual adaptation to another culture without losing tradition and identity; moving on from doctrinaire Soviet attitudes in education to embrace 'not knowing'; both organizers and routers learning from mistakes and from joint experience without guilt or shame; the need to protect reflective space amidst the constraints of time and geography. All Russian and UK contributors could finally acknowledge their shared luck to find themselves in the right place at the right time to respond to the collective revival of psychoanalytic practice in Russia.     

THE EFFECT OF THE ANALYST'S GENDER AND OTHER FACTORS ONPOST-TERMNATION PATIENT-ANALYST CONTACT: CONFIRMATIONBY A QUESTIONNAIRE STUDY

This questionnaire study was designed to confirm and further explore an earlier finding of a gender difference in post-termination patient-analyst contact, as well as to assess whether practices regarding post-termination contact have changed in the five-year interval since the first study. The hypothesis that women analysts are more likely to have post-termination contact with their analysands than men analysts was confirmed by the present study. Analysts who report thinking frequently about their most significant analyst are contacted by a much larger proportion of prior patients than those who rarely think about their analyst. Further, women analysts are more likely to feel they benefited from the analysis they consider their most significant analysis, and to feel positively about that analyst. In 1994, analysts were much more accepting of and more likely to propose post-termination contact than in 1989. What the analyst reports he/she says to the patient is associated with the likelihood of such contact.     

The effects of feedback about self and others on the recall and judgments of feedback-relevant information

After people have received feedback about the outcome of their behavior, their responses to information bearing on the validity of this feedback may be influenced by their desire to maintain a favorable self-image. This experiment investigated the cognitive mediators of these responses. Subjects who received negative feedback about their performance on an intelligence test disparaged intelligence tests in general and judged a report they had read to be unfavorable to intelligence tests. Nevertheless, they recalled more arguments in the report that were favorable to intelligence tests than did positive feedback recipients. These results contradicted the hypothesis that subjects selectively attend to information that helps them to maintain a positive self-concept in light of negative information about themselves. Rather, they may attempt to refute arguments that support the validity of the negative feedback they receive, and this relatively greater processing may facilitate the recall of these arguments later on. In contrast, there was no evidence that subjects try to refute information that calls the validity of positive feedback into question. Results had implications for two additional issues: first, whether the effect of performance feedback depends on whether it is received before or after information bearing on its validity; second, whether feedback has similar effects on recall and judgments by persons to whom it does not directly pertain.     

Improving comprehension and communication of risks about health

Many patients have severe difficulties grasping several numerical concepts that are related to their health, such as, for instance, the risk of suffering various diseases. Visual aids have been proposed as a promising method for enhancing risk communication and comprehension. In medical practice, however, not all patients benefit from visual aids. In a study conducted on a probabilistic, representative national sample in the United States, we identified a group of patients for whom visual aids are most useful: Those who have low numeracy but high graphical literacy skills. These patients have high scores in three abilities involved in graph comprehension: (1) the ability to read the data, (2) the ability to read the relations between the data, and (3) the ability to read beyond the data. Our results can have important implications for medical practice and for risk communication about health.     

The Beyond Within: An Interview about Aging with Gilda Frantz and Katie Sanford

This article is an interview with two veteran Jungian analysts and long-time friends on how Jungian psychology has helped them with the aging process and how they prepared themselves to grow older. They each discuss some of the best and worst times they have experienced in getting older. They also share what their relationships have been like with their deceased husbands, and they tell their favorite stories about Jung.     

Was bringt ?GRAS��?

Autonomous groups in the sense of GRAS (group analysis seminars) are groups without leaders. The small groups come together for self-experience within the framework of GRAS (Gruppenanalyse-Seminare, founded by Michael Lukas Moeller in 1977). Their members are group analysts who continue to participate in long-standing small groups on self-experience after completing their educational training as group analysts in GRAS. Participants of these groups (14 women and 11 men, average age 57.7 years) were interviewed about their experiences within GRAS and the subjective effects on their life. The interviews were evaluated in a qualitative research design. The findings show that the effects of GRAS are estimated to be extensive and very positive for private and professional life. The main modus to be in the group is experienced as retentive, acceptive and inspiring. Autonomous groups in the sense of GRAS form an important background of experience for trained group analysts themselves and continuously stimulate personal advancement and mental health.     

Are research participants truly informed? Readability of informed consent forms used in research

Researchers typically attempt to fulfill disclosure and informed consent requirements by having participants read and sign consent forms. The present study evaluated the reading levels of informed consent forms used in psychology research and other fields (medical research; social science and education research; and health, physical education, and recreation research). Two standardized measures of readability were employed to analyze a randomly selected sample (N = 108) of informed consent forms used in Institutional Review Board-approved research projects at a midwestern university during the 1987-1988 academic year. Results indicate that informed consent forms are typically written at a higher reading level than is appropriate for the intended population and that there are no consistently significant differences in readability among areas of research or between college student and noncollege student participants. Due to the unacceptably high reading level of the consent forms, one must question whether participants can comprehend the information contained in the consent form.