An approach to the study of analyzability and analyses: the course of forty consecutive cases selected for supervised analysis.

The cases of 40 consecutive patients, accepted for supervised psychoanalysis at the Treatment Center of The New York Psychoanalytic Institute, are reviewed. The process of the initial evaluation is examined as well as the nature of the patient group, the characteristics of the treatment, outcome, and follow-up data. A survey of a group of 42 patients from the private practice of a group of graduate analysts during the same period of time is also reported. Both studies are discussed in relation to methodological issues, and an approach is suggested for the study of assessment of analyzability and analyses through a systematic prospective study of analytic treatments conducted by experienced analysts.     

The role of reality testing in psychoanalysis: followup of 22 cases

As part of a prospective, longitudinal study of psychoanalytic outcome, 22 patients were evaluated for changes in their level of reality testing. These patients had been accepted for supervised psychoanalysis with candidates in training by senior analysts who had diagnosed them as neurotic. Psychological tests given prior to the beginning of analysis indicated, however, that more than one third of our sample demonstrated serious distortions in their perceptions of reality. When psychological tests administered one year after the completion of analysis were compared with these pretreatment tests, no significant improvement was found in the level of reality testing for the group as a whole. However, when excluding two patients who had suffered major traumas in the year following psychoanalysis, significant improvement in reality testing was found for the remaining 20 patients. Post-treatment interviews with the treating analysts revealed that in the course of analysis itself, approximately one third of these patients showed some disturbance in reality testing; only three of these patients showed significant improvement in the level of their reality testing during treatment. These findings suggest that while patients may not present clinically with evidence of impaired reality testing, such evidence may be available in psychological testing, and may become apparent in the course of the treatment.     

Changes in the level and quality of object relations in psychoanalysis: followup of a longitudinal, prospective study

As part of a prospective, longitudinal study of suitability for and outcome of psychoanalysis, 22 patients were evaluated for changes in the level and quality of their object relations. These patients had been accepted for supervised analysis with candidates in training by senior analysts who had diagnosed them as neurotic. The majority of these patients reported difficulties in relationships as at least one of their reasons for originally seeking psychoanalytic treatment. Prior to beginning analysis, each patient was given a battery of psychological tests. One year after the termination of analysis, the test battery was readministered and a followup interview was conducted separately with each patient and analyst. Ratings of change based on patient and analyst interviews and comparisons of psychological tests before and after treatment all showed statistically significant improvement in the level and quality of object relations for this patient group. The results of this study support what is often observed in clinical practice, that psychoanalysis has a positive effect on the level and quality of a patient's object relations.     

A COMPARISON OF HOLISTIC VERSUS DECOMPOSED RATING OF POSITION ANALYSIS QUESTIONNAIRE WORK DIMENSIONS

Recent studies have attempted to reduce the cost and intrusiveness of the Position Analysis Questionnaire (PAQ) by limiting the amount of information provided to the analyst, with consistently negative results. We examined an alternative technique for improving the cost-effectiveness of the PAQ that avoids the need to rate the hundreds of items that constitute the instrument. Three groups of raters (professional job analysts, graduate students in industrial psychology who were familiar with the PAQ, and PAQ-unfamiliar undergraduates) made direct holistic ratings of the PAQ dimensions for four familiar jobs. The holistic ratings were compared with decomposed PAQ dimension profiles obtained from the item-level ratings of the professional analysts. Cronbach accuracy analyses indicated near-zero convergence between the holistic and decomposed dimension ratings, even for the professional PAQ job analysts. We conclude that holistic rating of dimensions is not an effective means of reducing the cost of a PAQ job analyses and that it is likely to be similarly ineffective with task- or ability-based instruments.     

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.     

Repetition of deliberate self-harm: a study of the characteristics and subsequent deaths in patients presenting to a general hospital according to extent of repetition

Repetition of deliberate self-harm (DSH) is common. Some patients repeat multiple times. We have investigated the characteristics of repeaters, and mortality in three groups of DSH patients by repetition status. Data collected by the Oxford Monitoring System for Attempted Suicide were used to examine the pattern of repetition of DSH patients presenting to a general hospital between 1990 and 1997. Each patient was tracked through the monitoring system with regard to repetition. Patients traceable through National Death Registers were followed up until 2000 with respect to mortality. A total of 4,167 patients were studied of which 1,022 (24.5%) repeated at least once during follow-up. Using multinomial regression, past history of DSH was the variable most strongly associated with frequent (4+) and less frequent (1-3) repetitions. Risk of suicide was significantly increased in females with frequent repetition (7.7% dying by suicide), compared with both those with 1-3 repetitions (2.3%) and those not repeating (1.0%). The analyses were repeated for the 2,167 patients with no past history of DSH at their first presentation. Using multinomial regression, personality disorder was the only variable that was associated with 4+ repetitions compared with no repetitions, although a number of variables distinguished between patients with 1-3 repetitions and no repeat episodes. For clinicians assessing DSH patients, past history of DSH is the best predictor of infrequent and frequent repetition. In patients with no past history of DSH the presence of personality disorder increases the risk of frequent repetition of DSH.     

Relative preferences for edible and leisure stimuli in children with autism

Prior researchers have reported a tendency for individuals with developmental disabilities to select edible items more often than leisure items when those items are presented together in stimulus preference assessments. However, children with autism spectrum disorders (ASD), with whom many behavior analysts currently practice, are underrepresented in this body of literature. We conducted a replication of prior research with 26 children with ASD. Results indicated that edible items were more likely than leisure items to rank highly in our preference assessments, in concurrence with prior research. However, leisure items were also selected more often overall than in prior research, and significant individual variation was observed. These results suggest that preference assessments containing both edible and leisure stimuli can yield useful information for behavior analysts providing services to children with ASD, and the degree of preference for edible items noted in prior work may not be reflected in this contemporary population.     

Countertransference, supervised analysis, and psychoanalytic training requirements.

Because psychoanalysts have an ever expanding appreciation for the many factors that contribute to the psychoanalytic treatment process, they no longer view themselves simply as the receiver of the patient's transferences. When patient and analyst meet in the consulting room, they bring along with them a blend of intrapsychic and external ingredients--including countertransference--that make up the analytic soup. Candidates in psychoanalytic training must contend with even more sources of indirect countertransference reactions (Racker 1968) than experienced graduate analysts, due to aspects of the training experience itself. The author contends that minimum graduation requirements for supervised analyses are one such source of indirect countertransference. Four clinical examples of control analyses demonstrate this form of indirect countertransference during the assessment, opening, middle, and termination phases. These examples are followed by implications and recommendations for didactic psychoanalytic training curricula, countertransference awareness, supervision of control cases, institute governance policies and procedures, publication of clinical material, and future research.     

Multiple goals, writing strategies, and written outcomes for college students learning English as a second language

This study examined relations of achievement goals of writers who are speakers of English as a foreign language (EFL), the frequency of their writing strategy use, and the quality of their writing from a multiple goals perspective. The goal profiles of 57 EFL college students with similar writing proficiency were based on rating items of an unpublished scale; Group 1 had strong mastery and strong performance-approach goals, and two groups included students with only one strong mastery (Group 2) or performance (Group 3) goal. Think-aloud protocols indicated that the participants adopted 21 strategies in an argumentative writing task, classified into five categories. Group 1 was found to use writing strategies of monitoring or evaluating, revising, and compensating significantly more often than the other two groups, and produced better essays. Strong mastery and performance-approach goals might be beneficial for EFL college writers.     

The dark side of analytic conviction: impasses of omniscience and complacency

It is common for analysts to struggle with substantial periods of impasse, and with the associated subjective feelings of shame and failure, while analyzing patients who rely heavily on narcissistic defenses. Facing the feelings that accompany periods of impasse, while at the same time pushing oneself to take necessary creative risks, is a huge and painful task for the analyst if it is deeply confronted. These patients engage in false uses of the analytic process in which the pursuit of understanding is systematically undermined. In response, the analyst is susceptible to being drawn in to processes of mutual seduction, false conviction, and impasse. Through the analyst's partial living out of the patient's projective identifications (and eventually observing the patient's living out of the analyst's projective identifications), the analyst is able to gain a depth of understanding of the patient, of him- or herself, and of the interaction that might not otherwise be possible. Because analysts tend to employ theory defensively, it is essential that they attend, through self-analysis and consultation, to the ways in which they use it. Two cases are presented in which prolonged impasses were eventually understood and resolved.     

Therapeutic alliance and cohesion variables as predictors of outcome in short-term group psychotherapy

The current study explored the relative ability of aggregate therapeutic alliance and cohesion variables to predict short-term group therapy outcome. Data were collected from a comparative trial of two forms of time-limited group psychotherapy for complicated grief (Piper, McCallum, Joyce, Rosie, & Ogrodniczuk, 2001). The therapeutic alliance and elements of the cohesion construct were measured from the perspectives of each patient and the group therapist at intervals during the groups; scores were aggregated across assessments. Hierarchical multiple regression analyses, adjusting for the effects of treatment approach (interpretive vs. supportive) and specific group membership, demonstrated that the patient-rated alliance was a consistent predictor of outcome. Two cohesion measures, reflecting other participants' (therapist, other members) views of the patient's "fit" with the group, also accounted for variation in outcome. Implications of the findings for research and clinical practice, and the limitations of the measurement approach taken in this study, are considered.     

Hearing voices: the fate of the analyst's identifications.

Using detailed clinical examples, the author illustrates the function of conscious and unconscious identifications with former training analysts, supervisors, teachers, and theorists in the mind of the working analyst. As compromise formations, analytic identifications are the product of loving and aggressive wishes, defenses against those wishes, and self-punitive trends that accompany the analyst in the work. The analyst's stance at any given moment has an identificatory history that may become conscious at certain times with certain patients. While the analyst's identifications modify over time, following a predictable developmental path, they are never fully given up, but consciously and unconsciously remain an active part of the analyst's inner life. During the clinical hour they are responsive to both the analyst's and the patient's conflicts, and they coexist in a dynamic reciprocal relationship with the patient's inner life.     

Can Patients' Views of a Therapeutic System Predict Outcome? An Empirical Study with Depressive Patients

Using the principles of brief therapy as developed at the Mental Research Institute (MRI) in Palo Alto, this study examined how patients viewed psychiatrists' and significant others' attitudes toward the severity of their illness, as compared with their own attitude, and whether these views were related to outcome. Forty-one depressive inpatients were asked a two-part question — Who regards your illness as being more severe: (a) you or your significant others; (b) you or your psychiatrist? Two subsamples of patients were identified: those who viewed psychiatrists' and significant others' attitudes toward the illness as similar (equally structured systems) and those who viewed them as dissimilar (differently structured systems). Both groups showed equal and significant improvement during hospital treatment; but the group that viewed the attitudes held by psychiatrists and significant others as dissimilar reported improvement after discharge.     

Patient experiences with treatment in private practice compared with public mental health services

The study compared patient experiences with psychiatric treatment provided by private practitioners and public outpatient clinics. Questionnaires were completed by 642 outpatients in private practice and 6,677 outpatients in public clinics. The questionnaire included a measure of patient experiences comprising six items: treatment outcome, enough time for contact and dialogue with clinician, clinicians' understanding of patient's situation, suitability of therapy and treatment, clinician follow-up of planned actions, and influence on treatment. Patients in private practice had generally better experiences than patients in public outpatient treatment. The difference between private and public patients was largest for patients with poor self-evaluated mental health or those who had just one consultation in the previous three months. Private practitioners appear to have an important role in mental health services delivery, and patients have relatively good experiences with services. Further studies that assess the patient - clinician interaction in different mental health services may give further insights into potential service improvements.     

Recoding low-level simulator data into a record of meaningful task performance: The integrated task modeling environment (ITME)

The Integrated Task Modeling Environment (ITME) is a user-friendly software tool that has been developed to automatically recode low-level data into an empirical record of meaningful task performance. The present research investigated and validated the performance of the ITME software package by conducting complex simulation missions and comparing the task analyses produced by ITME with taskanalyses produced by experienced video analysts. A very high interrater reliability (> or = .94) existed between experienced video analysts and the ITME for the task analyses produced for each mission. The mean session time:analysis time ratio was 1:24 using video analysis techniques and 1:5 using the ITME. It was concluded that the ITME produced task analyses that were as reliable as those produced by experienced video analysts, and significantly reduced the time cost associated with these analyses.     

ÉmigrÉ analysts in Boston, 1930-1940

A brief history of the European analysts who settled in Boston during the first decade of the newly re-organized Boston Psychoanalytic Society/Institute, as part of the great intellectual migration fleeing from Hitler Germany and Austria. The term émigré was chosen as more inclusive, since not all were refugees forced to emigrate. The sequence of each analyst's arrival is traced, and their reasons for choosing Boston are identified, whenever possible.     

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.     

Psychodynamic focal group treatment for psychosomatic inpatients--with an emphasis on work-related conflicts

Conflicts arising from the work setting have remained a neglected issue in psychotherapy. To address this, the present study investigated the effectiveness of a manualized focal group treatment for psychotherapeutic inpatients suffering from vocational strains and conflicts and identified predictors of outcome. Cohorts of patients were assigned either to a treatment (N=144) or control condition (N=135). The group therapy intervention was found to be highly accepted by participants who were also more optimistic about returning to work and more favorable in their evaluations of treatment than patients in the treatment-as-usual condition. Group climate was found to be a predictor of favorable outcome. The findings suggest that a group therapy intervention with a strong emphasis on motivations and attitudes about work may be particularly suitable to deal with vocational conflicts and strains.     

The Therapeutic System as Viewed by Depressive Inpatients and Outcome: An Expanded Study

In an expansion of a previous study, we examined in which way depressive inpatients' views of psychiatrists' and significant others' attitudes toward the severity of their illness were related to outcome. Fifty-six patients were asked a two-part question —“Who regards your illness as being more severe: (a) you or your significant others; (b) you or your psychiatrist?” Two subsamples of patients were identified: those who viewed the psychiatrists' and significant others' attitudes as similar and those who viewed them as dissimilar. Both groups showed substantial and significant improvement during hospital treatment; but the group that viewed the attitudes held by psychiatrists and significant others as dissimilar had significantly fewer depressive symptoms by the end of a 3-month followup period. The findings were consistent with those of the original study, and with the hypothesis as derived from the Mental Research Institute brief therapy principles.     

The role of patients' ability to pay, gender, and smoking history on public attitudes toward cardiac transplant allocation: an experimental investigation.

This study assessed public attitudes toward organ allocation through vignettes that were varied by patient's ability to pay (insured or uninsured), gender, and smoking history (current, former, or never). Participants were 681 adults contacted at a state driver's license office who read a vignette about a heart transplant candidate and subsequently rated their likelihood and priority of offering transplantation. Results revealed main effects for patient smoking history exclusively. Post hoc analyses for likelihood of offering transplantation revealed that participants gave higher ratings for never smokers than current smokers. For priority of transplantation, analyses revealed higher ratings for never smokers than for both former smokers and current smokers. Results suggest that public opinion about organ allocation may include the consideration of smoking history but not ability to pay or gender.