Personal Genomic Testing as Part of the Complete Breast Cancer Risk Assessment: A Case Report

Patient access and utilization of personal genomic testing is becoming increasingly common. We present a case of a patient's personal genomic screening results leading to early detection of infiltrating breast ductal cell carcinoma via MRI scan. This case exemplifies the successful integration of personal genomic testing into the primary care setting, with the guidance and support of genetic counseling services. We discuss the scientific basis of the patient's genome scan results and risk assessment, and how this informed her decision-making and subsequent screening. We also expound upon the role of personal genomic testing as compared to other screening tests in the complete breast cancer risk assessment.     

Interaction of therapeutic process and alliance during psychological assessment

Utilizing a collaborative therapeutic assessment (TA) model proposed by Finn and Tonsager (1997), we examined the interaction between therapeutic alliance and in-session process during the assessment phase of treatment. This study compares the utility of the TA model (n = 38) versus a traditional information gathering model (n = 90) of assessment. The results of this study indicate that the use of a TA model may decrease the number of patients who terminate treatment against medical advice. The Session Evaluation Questionnaire (Stiles & Snow, 1984), Combined Alliance Short Form (Hatcher & Barends, 1996), and Penn Helping Alliance Questionnaire-Revised (Barber & Crits-Christoph, 1996) can reliably measure the patient's experience of the assessment. The psychological assessment process may impact the patient's experience of assessment feedback and aid in the development of a therapeutic alliance. The therapeutic alliance developed during the assessment was found to be related to alliance early in psychotherapy. We discuss the theoretical, clinical, and research implications of these findings.     

Application of The APA Practice Guidelines on Suicide to Clinical Practice

This article presents charts from The American Psychiatric Association Practice Guideline for the Assessment and Treatment of Patients with Suicidal Behaviors, part of the Practice Guidelines for the Treatment of Psychiatric Disorders Compendium, and a summary of the assessment information in a format that can be used in routine clinical practice. Four steps in the assessment process are presented: the use of a thorough psychiatric examination to obtain information about the patient's current presentation, history, diagnosis, and to recognize suicide risk factors therein; the necessity of asking very specific questions about suicidal ideation, intent, plans, and attempts; the process of making an estimation of the patient's level of suicide risk is explained; and the use of modifiable risk and protective factors as the basis for treatment planning is demonstrated. Case reports are used to clarify use of each step in this process.     

Lessons Learned from Two Peer-Led Mutual Support Groups

Abstract

This case report and analysis describe the formation of two peer-led mutual support groups conducted within the context of a Veterans Administration Medical Center. Based on our assessment of the success of one of these groups and the failure of the other, we offer several recommendations and suggestions to help promote this modality. More specifically, we hypothesize that such groups are more likely to be successful (1) if participants are transferred en masse from another group, (2) that, at least initially, housing the group in the same context as formal clinician-led groups or overlapping clinician-led and peer-led groups may help smooth the transition from authority-led treatment to a mutual peer support format, and finally, (3) that prior experiences in interpersonal process groups may promote the skills and cohesion to promote successful transition to mutual support.     

The body in analysis: authentic movement and witnessing in analytic practice

This paper will describe a form of active imagination called authentic movement, in which attention is given to the somatic unconscious. In authentic movement, patients are encouraged to focus inward and attend to any bodily sensations, images and feelings which may arise. In the process of focusing inward on one's bodily-felt experience, images, somatic memory and the accompanying feelings which arise are then available to be explored as a communication from the patient's unconscious. Authentic movement supports the individual in linking image with affect in that the individual re-experiences the somatic aspect of symbolization. What was previously conserved on the somatic level as unmentalized experience, can now begin to be taken up into the mind, thought about, and made available for analysis. In authentic movement, the analyst acts as a silent witness to the patient's explorations. The quiet focused attention of the witness helps to create a secure containing environment in which the person moving can experience a sense of feeling held and seen. The function of the witness is to hold the patient's experience in his own mind, particularly what is not yet mentalized. The witness utilizes his somatic countertransference, including any images, feelings and bodily responses which are generated by what is being communicated non-verbally, as a means of understanding and responding to the patient's material.     

Exploring a patient's shift from relative silence to verbal expressiveness: Observations on an element of the analyst's participation

By tracing a portion of close process of a patient's shifts from a relatively silent and inhibited stance to one in which he is beginning to verbalize more about his experience and fantasy, I will illustrate some tensions between the analyst's role as facilitating expressiveness and as occupying a place in the patient's internalized world. Since the analyst's functions as facilitator and as internal object (often an obstacle to the patient's expressiveness) are sometimes in conflict with one another, it is important for the analyst to be able to work internally with this conflict as he works with his patient. Splitting processes between these two functions may provide the analyst with cues related to the patient's and the analyst's resistance to understanding the patient's communication of unconscious conflict and the patient's recruitment of the analyst into the patient's internalized world.     

The real person of the analyst and his role in the process of psychoanalytic cure

This paper focuses on the real relationship with the analyst in the psychoanalytic situation as an aspect of the therapeutic process that leads to change. The role of free association, clarification, and interpretation of the transference are taken for granted as major activities of the analyst, and the real relationship with him is seen as a complementary but important ingredient for change. In particular, his emotional availability determines the climate of analysis. The concepts of neutrality, anonymity, and abstinence, though of importance as guideposts in the conduct of an analysis, have conceptual limitations that not infrequently bind the analyst in a stance that is not useful for the progress of the analysis. On occasion, confirmation by the analyst of the verity of an experience in the patient's early life facilitates the analytic process. This occurs particularly in situations of early trauma, but at times may include chronically traumatic early life experiences. An important motivating force in analysis is the patient's unconscious wish to find the ideal parent absent in early life experience, a wish that is experienced and ultimately analyzed. This is to be distinguished from a defensive idealized transference. Psychoanalytic developmental psychology contributes to our understanding of how the real person of the analyst, his emotional availability, his responsiveness at particular times, his attitude toward action and progressive change in the patient, affect the therapeutic process that leads to change.     

A force/displacement analysis of muscle testing

Manual muscle testing procedures are the subject of a force and displacement analysis. Equipment was fabricated, tested, and employed to gather force, displacement, and time data for the purpose of examining muscle-test parameters as used by clinicians in applied kinesiology. Simple mathematical procedures are used to process the data to find potential patterns of force and displacement which would correspond to the testing of strong and weak muscles of healthy subjects. Particular attention is paid to the leading edge of the force pulses, as most clinicians report they derive most of their assessment from the initial thrust imparted on the patient's limb. An analysis of the simple linear regression of the slope (distance vs force) of the leading edge of a force pulse indicates that a significantly large slope is indicative of weak muscles (as perceived by the clinician), and a small slope is indicative of strong muscles. Threshold criteria for slopes are specified to create a model that may discriminate between strong and weak muscles. The model is accurate 98% of the time compared to judgments of clinicians with more than 5 years of experience but is considerably lower for clinicians with less than five years of experience (64%). this accuracy rate indicates that the model is reliable in predicting the clinician's perception of muscle strength, and it also indicates that the testing procedure for muscle strength used by experienced clinicians in applied kinesiology are reliable. The experiment lays the groundwork for studies of the objectivity of muscle-strength assessment in applied kinesiology.     

Truth as a way of developing and preserving the space for thinking in the minds of the patient and the analyst

Clinical material from the analysis of a young patient diagnosed with borderline personality disorder and heavily dependent on drugs was examined to identify changes in setting that may be necessary to enable the psychoanalytical treatment of this type of patient. The article describes a lack of truth in the patient's life and the absence of a good enough space for thinking in her mind. In order to enhance the development of the capacity for symbolization in the patient's mind, the analyst had to become an object the patient needed. In order to do this the analyst had to manage setting alteration. Theoretical frameworks proposed by Ferenczi, Winnicott and Bion were used to guide the psychoanalyst's approach to this patient. The survival of the capacity for thinking psychoanalytically inside the analyst's mind when the setting has been significantly distorted by the disruptive behavior of the patient is guaranteed by the trueness of their link. It is suggested that maybe this is decisive for a successful psychoanalytical treatment of this type of patient.     

WORKING THROUGH ENVY: SOME TECHNICAL ISSUES

The author argues that envy appears in an analysis as a hostile, life-destroying force and is directed at the good qualities of the object, often manifesting in the patient's need to devalue analytic work that has been helpful. An intractable negative therapeutic reaction can thus become a persistent feature of an analysis. Sometimes powerful envy is silently operating beneath the surface, with the patient feeling continually wronged and mistreated by the object. The author argues that bringing the projected envy into the patient's personality structure is an important aspect of successful analysis, but that various technical problems have to be considered before painful insight can be achieved into the division in the patient's self. Presenting material from a relatively long analysis, she discusses some technical issues in dealing with these processes. Interpretation of envy can be a delicate matter, requiring consideration not only of how to interpret, but also of the nature of the countertransference and the form of the interpretation. A transference interpretation directed solely at the patient's self-destructive behaviour and destructiveness towards the object carries the risk of further stimulating the destructiveness, even if it is correct; it is also important to bring the patient's libidinal aspect into the interpretation.     

Idealization of the analyst by the young adult

Idealization is an intrapsychic process that serves many functions. In addition to its use defensively and for gratification of libidinal and aggressive drive derivatives, it can contribute to developmental progression, particularly during late adolescence and young adulthood. During an analysis, it is important to recognize all the determinants of idealization, including those related to the reworking of developmental conflicts. If an analyst understands idealization solely as a manifestation of pathology, he may interfere with his patient's use of it for the development of autonomous functioning.     

The analysis of drawing from memory performance in brain-damaged patients

The drawing from memory task is frequently used in cognitive neuropsychology to investigate visual processing impairments. However, in surprising contrast to most other neuropsychological tests, the analyses of results on this task are most often based solely on qualitative judgements about the normality of a patient's performance. In most case reports, these judgements are not made with reference to normative data and are not made by individuals who are impartial with respect to the study (that is, using a blind rating procedure). There are several grounds for arguing that such analyses are inadequate. First, seemingly abnormal drawings made by a patient may well be within the range of performance shown by control subjects. Second, judgments that are not based on a blind rating procedure are likely to be influenced by knowledge about the patient's performance on other tasks. We describe an alternative assessment procedure that addresses both of these concerns.     

The elusive concept of the psychoanalytic process

Although the term psychoanalytic process is frequently used, there is no consensual definition of its meaning. Some authors use it to designate a recognizable set of experiences within psychoanalysis. Others, a majority, use it as a synonym for the entire psychoanalytic experience, describing in detail what analysts do to achieve their goals. A range of views may be found between these extremes. A distinction is drawn here between the structure and content of the psychoanalytic process, which is regarded as a specific, definable entity--a red thread--within the psychoanalytic treatment experience as a whole, consisting of a microprocess and a macroprocess. The former is predominantly an amalgam of the patient's and the analyst's highly subjective experiences and entanglements, while the latter is predominantly an amalgam of the infantile and childhood origin of the patient's difficulties, as well as the analyst's conception of these difficulties based on a preferred theory. These ideas are used to formulate a definition of the psychoanalytic process based on clinical experience and are traced here primarily through lessons learned from a patient, Mr. K, over the course of a long and arduous analysis.     

Disorders of Eating in the Elderly

The most common eating disorder in the elderly in both community and hospital settings is food refusal. This may lead to weight loss and malnutrition with all the adverse consequences on independence and function. The management of disorders of eating in the elderly is a diagnostic and therapeutic challenge, requiring the combined skills of the medical and nursing staff. The causes are often multifactorial and require careful and repeated assessment of the patient's social, psychological, and medical history. Approach to treatment involves these factors, as well as ethical and cultural considerations. Eating is the most basic biological drive for survival in nature. In human societies there are additional cultural and social aspects that may override this instinct, as in the case of hunger strikes for political motives. In the elderly, food is one of the major sources of possible pleasure and it is the challenge for health providers to try and give this enjoyment to their patients for as long as possible.     

Analyzing disavowed action: the fundamental resistance of analysis

Several detailed analytic hours illustrate how, with the analyst's full participation, patients use the words, setting, and activity of analysis to gratify the very wishes they are analyzing, and so disavow the work of analysis. These gratifications, which are hidden in plain sight, are themselves disavowed in the apparent pursuit of analytic understanding. In this way the patient's and the analyst's use of the analytic situation becomes the fundamental resistance to the work itself. This process shares features in common with perversion. The painful but necessary task for both analyst and patient is to analyze this process as it is occurring, moment by moment, in the real time of the hour.     

Assessee and Assessor Experiences of Significant Events in Psychological Assessment Feedback

Although a growing body of scholarly work explores the unique utility and therapeutic uses of psychological assessment, less work has focused specifically on feedback, with few studies that have explored empirically the underlying processes that may describe the role of feedback in a successful assessment. The purpose of this project was to add to the discourse on this topic by engaging in an empirical study exploring assessee and assessor experiences of significant events in psychological assessment feedback. The methodology is qualitative and modeled after significant events research in the study of psychotherapy process. I analyze the accounts of 6 assessment clients and 6 assessment clinicians regarding key events in their experience of feedback.     

Assessee and assessor experiences of significant events in psychological assessment feedback

Although a growing body of scholarly work explores the unique utility and therapeutic uses of psychological assessment, less work has focused specifically on feedback, with few studies that have explored empirically the underlying processes that may describe the role of feedback in a successful assessment. The purpose of this project was to add to the discourse on this topic by engaging in an empirical study exploring assessee and assessor experiences of significant events in psychological assessment feedback. The methodology is qualitative and modeled after significant events research in the study of psychotherapy process. I analyze the accounts of 6 assessment clients and 6 assessment clinicians regarding key events in their experience of feedback.     

Assessment and Development of Rehabilitation Plans for Counselors Who Have Sexually Exploited Their Clients

Counselors who have sexually exploited clients require rehabilitation if they are to return to practice. The authors present a model, derived from their clinical experience with more than 1,000 cases, for the assessment and development of rehabilitation plans for impaired practitioners who have sexual contact with their clients. They present a classification system for the perpetrator, an assessment process that leads to the development of a rehabilitation plan, and a method for deciding if rehabilitation has been successful.     

Falling off the couch

The patient's therapeutic regression intensifies certain unconscious meanings of the analytic couch. In addition to representing the analysis or the analyst in general, the couch can represent the unconscious, or it may take on the symbolic significance of the analyst's or mother's arms, lap, breasts, or womb. When the genetic roots of the patient's transference include substantial experiences of disappointment, narcissistic injury, and mistrust, the theme of falling from the couch may emerge as a dream, an association, or even an enactment. This theme usually implies the presence of a deepening but mistrustful transference, based on earlier disappointments by the patient's primary objects. Falling off the couch may be associated with being dropped as an infant, rolling out of bed as a child, birth, miscarriage, castration, death, termination, defending against passive wishes, punishment for sexual or aggressive transgressions, escaping an attack, descending into the unconscious, or wanting to be picked up and comforted.