THE TRIADIC INTERSUBJECTIVE MATRIX IN SUPERVISION: THE USE OF DISCLOSURE TO WORK THROUGH PAINFUL AFFECTS3

The use of the psychoanalyst's subjective reactions as a tool to better understand his/her patient has been a central feature of clinical thinking in recent decades. While there has been much discussion and debate about the analyst's use of countertransference in individual psychoanalysis, including possible disclosure of his/her feelings to the patient, the literature on supervision has been slower to consider such matters. The attention to parallel processes in supervision has been helpful in appreciating the impact of affects arising in either the analyst/patient or the supervisor/analyst dyads upon the analytic treatment and its supervision. This contribution addresses the ways in which overlapping aspects of the personalities of the supervisor, analyst and patient may intersect and create resistances in the treatment. That three‐way intersection, described here as the triadic intersubjective matrix, is considered inevitable in all supervised treatments. A clinical example from the termination phase of a supervised analysis of an adolescent is offered to illustrate these points. Finally, the question of self‐disclosure as an aspect of the supervisory alliance is also discussed.     

Gender Verification: A Term Whose Time has Come and Gone

The process of testing to determine gender in putatively female athletes was developed in order to prevent cheating, but has devolved instead into a clumsy mechanism for detecting disorders of sexual development (DSD’s). In over thirty years of compulsory testing, individuals with DSD’s have been stigmatized and some have been denied the right to compete, although frequently their condition provided no competitive advantage. More recent guidelines require testing only on a case-by-case basis; the South African runner Caster Semenya was the first major test of this policy, and her experience points to the need for a more sensitive and confidential process. In addition, her case dramatizes the inadequacy of the term “gender verification.” Gender identity is a complex entity and resists simple classification. Sports authorities may set guidelines for who can compete, but they should refrain from taking on themselves the authority to decide who is and who is not a female.     

Prolonged Exposure Therapy and Irritable Bowel Syndrome: A Case Study Examining the Impact of a Trauma-Focused Treatment on a Physical Condition

Previous research has shown that psychological treatments, particularly those employing cognitive techniques, are particularly effective in the treatment of irritable bowel syndrome (IBS). It is presumed that these psychological interventions are effective at ameliorating the IBS by treating an underlying psychological disorder (often an anxiety disorder), which may be contributing to the autonomic reactivity. This case study examined the change in the physical symptoms of IBS for a patient seeking treatment for rape-related PTSD with comorbid conditions of major depression and panic. At posttreatment, the patient no longer met criteria for PTSD, major depression, or panic. In addition, her primary symptom of IBS, diarrhea frequency, was significantly improved. These findings were maintained at 3 and 9 months posttreatment. Implications for the assessment and treatment of IBS patients with PTSD are discussed.     

急症产科子宫切除术知情同意的分析

为保留产妇的生命权而牺牲其生育权的子宫切除术,仍是控制产科出血的最后手段。产科急症时,患者本人无法做出意思表示,子宫切除术的知情同意权由其法定代理人行使。子宫切除围术期,实施知情同意,仍存在许多法律盲点及实践困难。本文阐述了产科子宫切除术告知的法律义务、行为主体,以及告知患者子宫切除的方式。     

Going home: migration as enactment and symbol

Abstract :  The concepts of home and migration are briefly explored. Reference is made to the reflections of several writers on migration suggesting that migrants may experience alienation, even permanent melancholia. There is discussion of the need to mourn what has been lost and left behind, and of the challenge in analytic work with a migrant to relate to the pain of the individual's core self amid environmental and cultural losses. The paper outlines the history of an individual before her migration from Latin America to London, and tendency to idealize as a new arrival. The symbolization process is discussed and it is suggested that repetitive enactment in the analytic transference may have been needed for her internal reality of estrangement to be confirmed and differentiated from her culturally and socially isolated external life as a migrant. Only then could she mourn losses and symbolize her inner reality. It is suggested that through mourning and symbolization the significance of migration for the patient was worked with and transformed so that, following a second migration, an ordinary, good enough home could be made in a new place.     

Witnessing and Passing. Discussion of Prince's “The Self in Pain: The Paradox of Memory. The Paradox of Testimony”

The author indicates that she has two voices. One voice speaks to the patient's loneliness and detachment and her expectation to not be seen, believed, or acknowledged. This voice, housing the knowledge that events that remain unprocessed continue to have an impact, wants Dr. Prince to risk intrusion and preemption. This voice believes that it is worth it. The author's other voice considers bottomless wounds and speaks to the patient's need to build up healthy aspects of personality that is necessary to do the holocaust work. This voice holds that this is not the time for Dr. Prince to witness what happened to the patient, what the perpetrators of massive crimes did to her or what the onlookers saw and chose not to do. This voice says that the patients lead should be followed. The author elaborates on her two voices and indicates what she would have done had she been working with the patient.     

Procuring organs from a non-heart-beating cadaver: a case report

Organ transplantation is an accepted therapy for major organ failure, but it depends on the availability of viable organs. Most organs transplanted in the U.S. come from either "brain-dead" or living related donors. Recently organ procurement from patients pronounced dead using cardiopulmonary criteria, so-called "non-heart-beating cadaver donors" (NHBCDs), has been reconsidered. In May 1992, the University of Pittsburgh Medical Center (UPMC) enacted a new, complicated policy for procuring organs from NHBCDs after the elective removal of life support. Seventeen months later only one patient has become a NHBCD. This article describes her case and the results of interviews with the health care team and the patient's family. The case and interviews are discussed in relation to several of the ethical concerns previously raised about the policy, including potential conflicts of interest, the definition of cardiopulmonary death, and a possible net decrease in organ donation. The conclusion is reached that organ procurement from non-heart-beating cadavers is feasible and may be desirable both for the patient's family and the health care providers.     

A Single Intervention: A Visit to the Family

The following letter is reported unchanged except for disguised names. Concern with repairing disrupted relationships of adult members of a family with their own parents has been a matter of growing interest to a number of family therapists; Bowen (1), Boszormenyi-Nagy (2), and Framo (3), among others have stressed the importance of sending family members back to their families of origin. This report makes no effort to formulate the process in any particular theoretical framework (i.e., as reestablishing connectedness after an “emotional cut-off” or rebalancing a ledger of fairness, or whatever) but is intended only to illustrate the kind of outcome one may hope for in prescribing such a maneuver. It is offered simply as a clinical note. The letter needs little prefatory explication. Mr. Jack Newburgher had been a patient in psychoanalytic treatment for four years, with a quite successful outcome. On two occasions in the course of his therapy a joint session had been held with Mr. Newburgher and his wife, Muriel, when changes in his behavior had precipitated crises in the marital relationship. His therapy had terminated about two years before the visit referred to in the letter. Mr. Newburgher had called and asked for a joint consultation with Muriel about an acute family problem they were experiencing. Some — not all — of the background material was described, not nearly as coherently as it is reported in Muriel's letter, but in sufficient detail to make it plain that she was in distress about having to withdraw completely from her parents and that their family was in disarray as a consequence of her distress. The acuteness of the emotional disturbance, against a background of a lifelong adversary relationship between Muriel and her father and a history of ten years of illness on her fathers' part, suggested that the distress was the product of Muriel's anxiety and guilt over a decision to cut herself off completely from her parents. As a consequence, Muriel was urged to visit her family of origin, with the caveat that she might indeed discover them to be malignantly self-centered people indifferent to their effect on her and her family, but that she would at least have the gratification of having tried. The reference to “speaking French” was to the therapist having suggested that, on the other hand, she might find that her parents expressed their feelings in a different modality from her definitions of how feelings should be expressed, much as though their native tongue were French and she were insisting that they must speak to her in English.     

A body with chronic fatigue syndrome as a battleground for the fight to separate from the mother

I describe the therapy of a 20-year-old woman who believed that her difficulties in concentrating and remembering were caused by her 'ME' (Myalgic encephalomyelitis, Chronic fatigue syndrome, or CFS). She had been fathered by a man who never left his own wife. Work with her dreams revealed a within-body drama in which she was locked in an unspeakable fight to the death with her mother. Her symptoms improved after parallels between a dream and an accident showed her own self-destructive hand in her story. Another dream, reflecting her first 'incestuous' affair, showed her search for her original father-self as someone separate from mother, and a later affair provided a between-body drama, helping her to own the arrogant and abject traits she had before seen only as her mother's. I show how we worked in the area of Winnicott's first 'primitive agony' as experienced by a somatizing patient, stuck in a too-close destructive relationship with her mother-body. I discuss how analytical work can be done with the primitive affects and conflicts against which the ME symptoms may be defending.     

The Case of Helen D.: A Woman Who Learned to Suffer

Despite our earnest wish to be useful to patients, we sometimes fail. Part of the difficulty often has to do with the expectations that the patient brings to therapy. Another contribution to an impasse may be the psychiatrist's theoretical orientation. This review illustrates a playful distortion of the doctor-patient relationship so as to develop an alliance with a difficult patient. The involvement of part of her family in the long-term treatment facilitated her growth out of a biopsychosocial swamp.     

Did You Say He Has a Hitler Mustache?: Analytic Vulnerability and Destabilization in the Face of Trauma

This paper looks at analytic vulnerability and destabilization through a detailed clinical example. There are different ways in which we may be vulnerable with our patients. In this paper I describe the raw and sudden vulnerability of allowing ourselves to be in a place of not knowing when both patient and analyst are unable “to see.” I describe an experience in which I lose my ability “to see,” both literally and metaphorically, while in session with a patient who is unable “to see” because she has dissociated her experience of loss and her experience of a sense of danger when in the presence of her stepfather. I link this clinical experience to the patient’s dissociated feelings and to my history of intergenerational trauma as well to current cultural violence and hate.     

Not a Laughing Matter: Sexual Harassment as “Material” on Workplace-Based Situation Comedies

In her book Sexual Harassment of Working Women Catherine MacKinnon (1979) suggested that “Trivialization of sexual harassment has been a major means through which its invisibility has been enforced. Humor, which may reflect unconscious hostility, has been a major form of that trivialization” (p. 52). In other words, making jokes at women's expense and treating sexual harassment as not serious have contributed to its persistence. Situation comedies can be seen as gauges for what is considered humorous in American culture. To explore the tone of and mood toward sexual harassment in contemporary American society, themes and content of “humorous” material on 56 episodes of five workplace-based situation comedies were examined. Results showed that although sexual harassment is rarely discussed on situation comedies, gender harassment is frequently used as “material,” which leads to further trivialization of a serious social problem.     

Persistent visual aura following catheter ablation in a patient with WPW syndrome

We report a patient who has had persistent visual disturbances since she underwent catheter ablation to treat her Wolff-Parkinson-White (WPW) syndrome. We examined her visual symptoms carefully and quantitatively by means of our newly developed method combining image-processing and psychophysics. We first simulated the patient's visual symptoms using image-processing techniques. Since the simulation indicated that she would be very sensitive to the edges of the visual stimuli, we evaluated her sensitivity to the edges using psychophysics. The results indicated that she was hypersensitive to the clear-cut edges of the visual stimuli. Her visual symptoms were very similar to those of visual aura of migraine, rather than those of photosensitive epilepsy. Magnetic resonance imaging (MRI) and single photon emission computed tomography (SPECT), electroenchepalogram (EEG), and visual-evoked potentials (VEP) in the patient were normal. No abnormalities in her fundus, visual field, or electroretinogram were found, either. Transesophageal echocardiography with bubble study indicated that she had a preexisting right-to-left shunt. We hypothesize that visual aura of migraine was triggered and made persistent by the catheter ablation in this patient. Although the relationship between migraine, catheter ablation, and right-to-left shunts is unknown, previous studies on the transcatheter closure of patent foramen ovale suggest a possible link between them. Catheter ablation in patients with migraine and preexisting shunts may lead to exacerbations in migraine symptoms.     

On talking-as-dreaming

Many patients are unable to engage in waking-dreaming in the analytic setting in the form of free association or in any other form. The author has found that 'talking-as-dreaming' has served as a form of waking-dreaming in which such patients have been able to begin to dream formerly undreamable experience. Such talking is a loosely structured form of conversation between patient and analyst that is often marked by primary process thinking and apparent non sequiturs. Talking-as-dreaming superficially appears to be 'unanalytic' in that it may seem to consist 'merely' of talking about such topics as books, films, etymology, baseball, the taste of chocolate, the structure of light, and so on. When an analysis is 'a going concern,' talking-as-dreaming moves unobtrusively into and out of talking about dreaming. The author provides two detailed clinical examples of analytic work with patients who had very little capacity to dream in the analytic setting. In the first clinical example, talking-as-dreaming served as a form of thinking and relating in which the patient was able for the first time to dream her own (and, in a sense, her father's) formerly unthinkable, undreamable experience. The second clinical example involves the use of talking-as-dreaming as an emotional experience in which the formerly 'invisible' patient was able to begin to dream himself into existence. The analyst, while engaging with a patient in talking-as-dreaming, must remain keenly aware that it is critical that the difference in roles of patient and analyst be a continuously felt presence; that the therapeutic goals of analysis be firmly held in mind; and that the patient be given the opportunity to dream himself into existence (as opposed to being dreamt up by the analyst).     

On psychic elements in a case of autistoid perversion

The paper explores the formation of psychic elements from an epistemological point of view, drawing on the work of Bion to examine a clinical case of autistoid perversion. Distinguishing the qualification of psychic elements from the realization of pre‐conceptions, the paper argues that psychical elements are constituted through a mutually shared experience of presence, and so they should be understood in a paradoxical way – through being‐O and transformations into K. These ideas are explored via a clinical case concerning a patient with an autistoid–perverse organization. The patient had been denied any bodily contact with her parents during her first year of life due to an infection; in later life she exhibited an autistoid coprophilic perversion. During the course of her treatment, as it became possible to break down the autistoid organization, the nameless contents surfaced in a mutually shared experience of presence. The analyst was able to hold on to their meaning, which was unavailable to the patient. The absent analyst, however, turned into the mother who ‘put the child down’ and was experienced by the patient as a suicidal threat. In being‐O, the analyst was able to endure the paradox of being the one who ‘put her down’ in order not to put her down; the paradox of being‐O functioned as a container for the destructive objectal dimension of the state of ‘being put down’.     

Making of Victim a Patient: Sexually Abused Children and the Consequences of Unprofessional Help

The disclosure of sexual abuse by a child not only disturbs the mental peace of the family members but influences their attitudes towards the victim as well. This article explores how the diverse types of attitudes of the family members towards the victim and un-fulfillment of role expectation of a victim from his/her family members make him/her a patient. An attempt has also been made to analyse how the reluctance of parents to take any professional help impedes the recovery of the child along with the strategy a child adopts to cope with this traumatic event of his/her life. The child wants love and support from his/her close relatives, besides expecting protection from them. In such circumstances even a little negligence from any of the family members or their unsupportive and unpractical attitudes towards the victim, makes him/her a silent sufferer. A sense of helplessness develops in her/him and later on this sense of helplessness makes him/her a patient of depression.     

THE PSYCHOTHERAPY OF A MALE ANORECTIC3

The author describes the way in which a male anorexic patient came to be understood in once‐weekly psychotherapy. The findings are similar to recent psychoanalytic ones about female anorectics, but add that he was preoccupied with display and that there was an erotised transference in the oral mode. Of two major themes, the first was a food obsession; the food was felt concretely to be the mother as in a symbolic equation, and the conflict about eating represented a wish for and fear of fusion with her. The second major theme concerned exhibition; the self, as seen in two screen memories, was felt to be uncomfortably on show. Meanwhile the patient was preoccupied with a self‐displaying maternal object, which was prominent in the transference. This perception of the object served as a defence against envy, although the defensive aspect may have been added to by an actual experience of a mother who functioned operatively, giving food rather than loving attention. The patient employed primary‐process thinking defensively against selfobject differentiation, which would have excited further awareness both of envy and of the real deficiencies of his primary objects. The author raises the possibility that the anorexia functioned as a perversion, binding and organising the core complex about fusion.