Medicating Patients in Psychoanalytic Therapy: Implications for Introjection,Transference, and Countertransference

If a patient comes for psychotherapy or psychoanalysis, why medicate him with psychotropic drugs? The answers to this question are explored and addressed from several points of view. The central hypothesis of this paper suggests that most of the reasons for medicating patients have to do with therapist's unresolved countertransference issues. Furthermore, medicating a patient may have deleterious effects on his introjected sense of self, and impacts the transference relationship in a significant way. The issues surrounding medication as adjunctive therapy are elucidated and clarified in terms of rationale, efficacy, and the impact on the psychotherapeutic relationship. Psychoanalytic solutions are offered and discussed.     

Psychoanalytic Psychotherapy for Severely Disturbed Borderline Patients: Observations on the Supervision Group of Psychotherapists

The authors describe the role of a supervision group of psychotherapists within a wider therapeutic field for severely disturbed borderline patients. The group concentrates on the transference and countertransference, seen according to Racker’s distinction between concordant and complementary identifications. The implications of the prevalence of the complementary identifications over the concordant identifications of the therapists to their patients and the resulting regression to primitive defense mechanisms can be counterbalanced by the group’s integrative functioning as receiver (1) of a variety of information about the patient, (2) of the therapist’s attempt to understand and synthesize, and (3) of the therapist’s countertransference reactions to his patient. The major discrepancies between the various conceptions of the borderline patients’ psychic world and the appropriate therapeutic technique to be applied are also discussed, as well as the way the group filters the information and integrates the therapeutic thought. It might be said, therefore, that, in the “inpatient” phase of the individual psychotherapy, the group of psychotherapists functions, for the patient and the treatment, in a synthesizing context, as it provides the therapist with a space of integration for his split-off part of self and object representations, which the therapist makes use of for his patient.*Members of the Athens University Project for Borderline Patients’ research team consisting of psychoanalysts and psychotherapists, Eginition Hospital, 74 Vas Sophias Avenue, Athens 11528, Greece.Maria Chatziandreou, M.D., is a member of the Hellenic Psychoanalytical Society.Haris Tsani, M.D., is a candidate of the Hellenic Psychoanalytical Society.Nikos Lamnidis, M.D., is a candidate of the Hellenic Psychoanalytical Society.Claire Synodinou, Ph.D., is a member of the Paris Psychoanalytical Society and an associate professor at Panteion University, Athens.Grigoris Vaslamatzis, M.D., is a training analyst of the Hellenic Society of Psychoanalytic Psychotherapy and an associate professor of psychiatry at Athens University.Address correspondence to: Maria Chatziandreou, M.D., 1-3, Skippi Street, 11525 Athens, Greece.     

Divorce Terminable and Interterminable: A Psychoanalytic and Interdisciplinary Approach

Psychoanalytic therapy of divorce studies positive and negative aspects of couples' bonds, focusing on the guilt and narcissistic wounds of the multiple losses. Interactionally structured aspects of identity are especially difficult to mourn in the interminable divorces where separation is incomplete. A case demonstrates work with families to transform negative links, often including consultation with the legal system and work with the children.     

There is Room for Even More Doublethink: The Perilous Status of Psychoanalytic Research

The opposition between psychoanalysis and systematic interdisciplinary research is to be regretted. The target article attempts to bridge the intellectual divide and for this aim as well as the intellectual adroitness shown it is to be celebrated. Much harder to understand is the high level of affect generated by the debate. Accusations of “doublethink” are helpful. The present paper, like the target paper it follows, attempts to develop an understanding of the position of those who are categorically opposed to interdisciplinary systematic research linked to psychoanalysis. Appreciating the perspective of those deeply opposed to such work could help to create a shared agenda from which our troubled discipline could benefit. This is predicated on the possibility of an open collegial dialogue which this journal was founded to create.     

Whose Who in the Psychoanalytic Situation: Subject,Object, and Enactment in the Relational and Contemporary Kleinian Traditions

The concept of enactment, although it has probably has become an overused term in the Relational literature, is a relatively new one for the Contemporary Kleinians of London. In explicating and synthesizing these different theoretical perspectives (Relational and Contemporary Kleinians), the author's primary focus is to tackle the notion of subject and object, in the context of enactment. The author first delineates the relationship between reality and fantasy, and each theory's notion of enactment. In doing so, the author shows how these differing theories and their related notion of therapeutic action inform the kind of object the analyst sees himself or herself as. The author also addresses the technical implications related to the consequences that arise for the analyst as an object of the patient's transferences and projections, including how the analyst extricates himself or herself from the enactment. Two previously published vignettes are used for the purpose of comparison. The author argues for a complementary technical stance comprising two analytic modes: analyst as subject and analyst as object.     

More Things in Heaven and Earth: Sharing the Psychoanalytic Understanding of Religion

Links between current religious status and both childhood play style and adult personality (Five-Factor Model) were explored in a Canadian undergraduate sample. The lifelong religious reported being less open to experience, but more agreeable and conscientious, relative to apostates (who left their childhood faith for no faith), switchers (who migrated to a different faith), converts (who adopted faith since childhood), and the lifelong nonreligious. Relative to the two lifelong groups, apostates and switchers—and, to a lesser extent, converts—reported stronger interest and engrossment in pretend play involving props, peer collaborators, and/or imaginary characters, as well as less interest in organized sports. A childhood predilection for pretend play may function as a marker of greater ability and willingness to consider the implications of experiencing the self in different roles in an “as if” world. In turn, this predisposition may eventuate in a significant ideological shift in response to unmet cognitive and/or emotional needs, consistent with current understandings of religious change.     

The Impact of Theory on Psychological Testing: How Psychoanalytic Theory Makes Diagnostic Testing More Enjoyable and Rewarding

The psychometric properties of three scales of alexithymia were examined in a sample of 187 female undergraduates. The Shalling Sifneos Personality State (SSPS) and the Minnesota Multiphasic Personality inventory (MMPI) Alexithymia scale had little internal consistency. The scored archetypal test with nine elements (SAT) had very low interrater reliability. As predicted, the three measures were not significantly related to one another and the SSPS had a more clearly defined factor structure than the MMPI scale. The MMPI and SSPS scales were differentially related to measures of symptomatology but were similarly related to extraversion, absorption, and SAT scores. Of the three scales, the SSPS appeared to have the highest content validity. The results suggest that alexithymia is not a unitary construct and that its reification as such may be premature.     

Examining Relationships Between Physicians and Their Patients: A Psychoanalytic Model

This is a study of a group of physicians' reflections about their communication with patients. Using an applied psychoanalytic framework for self-inquiry in groups, the authors summarize their findings and provide a model for others to use. They describe their method of conducting and studying three physician groups. The authors identify six essential dynamics within groups and illustrate the dynamics with examples of physician reflections. They summarize further their observations about the composition, dominant themes, and phases of development for each group. The intent of the self-inquiry groups—to clarify physicians' habits and thought patterns about patients—is upheld in the report's conclusion, in which the authors report participants' evaluation of their learning experience. Recommendations are made for analysts to apply the model in work with general physicians.     

Transference Focused Psychotherapy for Patients with Comorbid Narcissistic and Borderline Personality Disorder

Clinical experience involving the treatment of patients with comorbid borderline and narcissistic personality disorders suggests that this patient population is among the more difficult to treat within the personality disorder spectrum. In this article, we present refinements of Transference Focused Psychotherapy (TFP) based on our clinical experience with and research data on patients with comorbid narcissistic personality disorder/borderline personality disorder (NPD/BPD). We briefly review object relations formulations of severe narcissistic pathology, as well as recent research in attachment and the allied concept of mentalization, which have provided a new lens through which to view narcissistic disorders. The research findings from two randomized clinical trials demonstrating the efficacy and effectiveness of TFP are presented. The data from the two Randomized Clinical Trials (RCT) allowed for the study of the characteristics of the subgroup of borderline personality disorder patients who have comorbid NPD/BPD. Findings on comorbidity, attachment status, capacity for mentalization, and level of personality organization of borderline patients with comorbid NPD/BPD, compared with borderline patients without comorbid narcissistic pathology (BPD), are presented. Clinical implications of the observed group differences are discussed, with a focus on refinements in the technique of TFP. Clinical case material is presented to illustrate the specific challenges posed by narcissistic patients to carrying out TFP in each phase of treatment.     

The CAMS Approach to Working with Suicidal Patients

The Collaborative Assessment and Management of Suicidality (CAMS) is a novel clinical protocol designed to quickly identify and effectively engage suicidal outpatients in their own clinical care. The CAMS approach emphasizes a thorough and collaborative assessment of the patient's suicidality that then leads to problem-solving treatment planning that is coauthored by the clinician and the patient. This approach is specifically designed to launch a strong therapeutic alliance creating an effective treatment trajectory. The CAMS approach is designed to modify and change clinician behaviors in terms of how they initially identify, engage, conceptualize, assess, treatment plan, and manage suicidal outpatients. Critically, however, CAMS does not usurp clinical judgment or dictate treatment modality. Preliminary research has shown that CAMS leads to faster resolution of suicidality and may decrease nonmental health medical utilization. Given the challenges of clinical work with suicidality, increased concerns about malpractice liability, and the decreased use of inpatient hospitalization, CAMS provides a potentially important new approach to working with suicidal individuals on an outpatient basis.     

Psychoanalytic Controversies: The relationship between psychoanalysis and schizophrenia

In this article, the author considers psychoanalysts' current attitudes towards schizophrenia. After early optimism of a psychoanalytic approach, interest has waned, other than in the field of first-onset psychosis. This was because of poor outcome figures and regarding schizophrenia as now having a biological, rather than psychological, base. The author argues that there is a paradox, because only psychoanalysis offers a framework for relating to psychotic patients in a way that helps them to make sense of their experiences. A framework is described, with clinical examples, to illustrate the application of analytic thinking to patients with schizophrenia. Psychoanalysis needs to revitalise its attitude to psychosis, as it has a significant contribution to make within general psychiatry, not least in the training of the next generation of psychiatrists.     

Sexual Contact Between Psychologists and Their Former Therapy Patients: Psychoanalytic Perspectives and Professional Implications

Data was analyzed from the semi-structured interviews of 6 heterosexual male psychoanalytic psychotherapists who by self-report had not engaged in a post-termination sexual involvement. The focus of each interview was to elicit the participants' views about sexual contact between psychotherapists and their former therapy patients, as well as their related attitudes towards Standard 4.07 of the APA Ethics Code (1992). The results suggested great disparity of opinion regarding what might constitute acceptable, ethical behavior in this domain. Nonetheless, all the clinicians agreed that the potential for harm resulting from post-termination sexual involvements was great, They all shared the beliefs that transference did not resolve with termination, that professional responsibilities continued after treatment ended, and that power differentials between therapist and patient lingered, perhaps in perpetuity. However, it was determined to be premature to replace the current Standard 4.07 with an absolute prohibition against sexual involvements between therapists and their former patients.