The scientific status of psychoanalytic clinical evidence (I)

The main source of evidence for psychoanalytic theory comes from the clinical situation. Yet recent empirical studies in verbal conditioning and the social psychology of persuasion indicate that psychoanalysts and therapists of other schools are speciously validating their own theories by unwittingly influencing their patients’ behavior. In the light of this evidence it is small wonder that psychoanalysts consistently ‘validate’ psychoanalytic theory in their clinical practice while therapists of other schools ‘validate’ their own theories in their clinical practice. Although Freud was not unaware of the problems of ‘suggestion’ and the conflicting evidence of rival schools of psychotherapy, he never met these problems successfully. Contemporary psychoanalysts have added little to Freud's original position. One recent attempt, by Fritz Schmidl, to formulate new criteria for the correctness of psychoanalytic clinical interpretations, does not completely escape the problem of suggestion and has new problems of its own.     

Grasping psychoanalysts’ practice in its own merits1

The central objective of this presentation is to reflect on the obstacles involved in the task proposed by the Chicago Congress, which is to explore convergences and divergences in psychoanalytic practice. The author discusses two major obstacles. First, the epistemological and methodological problems in relation to the construction of theory in psychoanalysis and especially the inaccessibility, in any reliable way, of what psychoanalysts really do in the intimacy of their practice. He proposes to separate, at least in part, theory from practice in psychoanalysis, in an attempt to grasp psychoanalysts' practice in its own merits. He then outlines a phenomenology of the practice of psychoanalysis, which reveals that, in their work with patients, analysts are guided more by practical reasons than theoretical reasons; that is, their interventions are predictions rather than explanations. Since these practical reasons need to be validated constantly in the analytic relationship based on their effects, he discusses the subject of validation in the clinical context of the core theory of therapeutic change in psychoanalysis, that is, the conditions required for clinical practice to satisfy the thesis of an inseparable union between gaining knowledge and cure. He ends by challenging the core of the psychoanalytic theory of change, arguing that it neither does justice to the practice of psychoanalysts nor to contemporary knowledge of processes and mechanisms of therapeutic change. Finally, he proposes that we detach practice from theory, in order to study the former in its own merits, utilising a plurality of methods ranging from systematic investigation to the recent methodology of the Working Party.     

The Therapeutic Alliance in Multicultural Practice

Abstract

The therapeutic relationship rests on both an emotional bond with the therapist and a rational, “working” connection. Both dimensions of the alliance have relevance for multicultural clinical work. There have been many contributions to multicultural practice that emphasize either cognitive or emotional levels of the alliance. This paper uses both empirical studies and clinical papers to synthesize both the emotional and the rational perspectives on the multicultural alliance. Examples are drawn from literature, published case examples, and the author's own clinical practice.     

B超与X线影像诊断肾积水的比较

通过结合临床实践与数据,以临床上常见的肾积水为例,用哲学的观点比较分析B超诊断与X线医学影像诊断的各自特点,有其共同之处,又有其各自突出的特点,在超声诊断的学习中要合理综合应用之,为临床诊断提供更多有价值的诊断信息,并能让病患了解和理解医学影像诊断学。     

Psychotherapy and problem-solving appraisal: Science informing practice to help people solve unsolvable problems

Clients come to psychotherapy because they have difficult and stressful problems that they are unable to resolve on their own. Advances in the applied problem-solving literature can now inform clinical interventions. This article focuses on the most commonly used problem-solving assessment tool, the Problem-Solving Inventory (PSI); empirical findings from well over 120 studies are used to inform clinical practice. The article will first discuss the PSI, what it measures, and then summarize the empirical research findings most relevant for clinical interventions. Second, based on the PSI empirical research, therapeutic and preventative implications will be discussed with clinical illustrations. The article concludes with a number of implications for psychotherapy both in terms of remedial and preventative interventions.     

Context of practice,practice of context: A psychotherapeutic meditation

Intended as an essay on the perennial topic of the relation between theory and practice, which will not be all theory and no practice, this paper draws on contemporary philosphy of science and clinical theory to catalyze the reader's own further reflections on the topic by suggesting that the meanings of theories and practices are context-dependent, and so the question can never be answered in the abstract, and that the separation of theory and practice is something we can do only in theory, never in practice.     

Supervising away from home: clinical,cultural and professional challenges

This paper explores some challenges of supervising clinical work of trainees, known as ‘routers’, who live in countries with diverse cultural, social and political traditions, and the analysts who travel to supervise them. It is written as an evolving dialogue between the authors, who explore together the effects of their own culture of origin, and in particular the legacy and values of their own training institutes on the styles and models of analytic supervision. Their dialogue is framed around the meaning of home and experiences of homesickness for analysts working away from home in an interactive field of strangeness in countries where analytical psychology is a relatively new discipline. The authors outline the findings from their own qualitative survey, where other supervisors working abroad, and those they have supervised, describe their experiences and their encounters with difference. The dialogue ends with both authors discussing what they have learned about teaching and supervising abroad, the implications for more flexible use of Jungian concepts, and how such visits have changed their clinical practice in their home countries.     

Standards,Harmonization and Cultural Differences: Examining the Implementation of a European Stem Cell Clinical Trial

ABSTRACT

A complex set of European regulations aims to facilitate regenerative medicine, harmonizing good clinical and manufacturing standards and streamlining ethical approval procedures. The sociology of standardization has elaborated some of the effects of regulation but little is known about how such implementation works in practice across institutions and countries in regenerative medicine. The effects of transnational harmonization of clinical trial conduct are complex. A long-term ethnographic study alongside a multinational clinical trial finds a range of obstacles. Harmonization standardizes at one level, but implementing the standards brings to the fore new layers of difference between countries. Europe-wide harmonization of regulations currently disadvantages low-cost clinician-lead research in comparison to industry-sponsored clinical trials. Moreover, harmonized standards must be aligned with the cultural variations in everyday practice across European countries. Each clinical team must find its own way of bridging harmonized compulsory practice with how things are done where they are, respecting expectations from both patients and the local hospital ethics committee. Established ways of working must further be adapted to a range of institutional and cultural conventions that affect the clinical trial such as insurance practices and understandings of patient autonomy. An additional finding is that the specific practical roles of team members in the trial affect their evaluation of the importance of these challenges. Our findings lead to conclusions of wider significance for the sociology of standards concerning how regulation works and for medical sociology about how trial funding and research directions in stem cell medicine intersect.     

Religious Values in Clinical Practice are Here to Stay

Research to date has shown that health professionals often practice according to personal values, including values based on faith, and that these values impact medicine in multiple ways. While some influence of personal values are inevitable, awareness of values is important so as to sustain beneficial practice without conflicting with the values of the patient. Detecting when own personal values, whether based on a theistic or atheistic worldview, are at work, is a daily challenge in clinical practice. Simultaneously ethical guidelines of tone-setting medical associations like American Medical Association, the British General Medical Council and Australian Medical Association have been updated to encompass physicians’ right to practice medicine in accord with deeply held beliefs. Framed by this context, we discuss the concept of value-neutrality and value-based medical practice of physicians from both a cultural and ethical perspective, and reach the conclusion that the concept of a completely value-neutral physician, free from influence of personal values and filtering out value-laden information when talking to patients, is simply an unrealistic ideal in light of existing evidence. Still we have no reason to suspect that personal values, whether religious, spiritual, atheistic or agnostic, should hinder physicians from delivering professional and patient-centered care.

     

Self‐supervision,surveillance and transgression

Transgression is not only an inevitable part of systemic supervision but is also necessary if we are to work towards innovative and inclusive supervisory and therapeutic practice. Defying culturally generated ‘rules’ of systemic practice can allow for more relevant and productive ways of talking. Systemic practitioners are increasingly finding themselves trying to practice systemic therapy in employing authorities and training courses which are dominated by inflexible professional narratives and manualised procedures. Our profession is committed to ethical inner and outer dialogue, to self‐ and relational reflexivity as distinct from the rule‐bound surveillance culture in which we live and work. Systemic supervisors and therapists may find themselves at odds with monological institutional discourse and attempts from within our own profession to manualise practice. I introduce examples from supervisory conversations to illustrate how supervisors can develop more culturally sensitive practices through supporting practitioners to hear and have heard their own marginalised and oppressed voices and those of their clients.     

Self-disclosure with all-male groups

Given the relational deficits men bring to a group, therapist self-disclosure is particularly pertinent with all-male groups. The use of this intervention reflects the author's long experience with such groups. The author writes from an interpersonal, collaborative model of group therapy, and discusses types of self-disclosure and the guiding principles in their use. Drawing primarily from his own practice, the author presents and discusses clinical vignettes that illustrate both helpful and nonhelpful uses of self-disclosure.     

Reflections on knowledge and experience

As analysts become more experienced, theoretical knowledge becomes more integrated and implicit and is gradually transformed into the practical wisdom (phronesis) described by Aristotle. While this leads to greater freedom in ways of working, it remains conditional on the consistent disciplined practice represented by the analytic attitude. In the context of my own development as an analyst, I suggest that increasingly the analyst works from the self rather than the ego and link this with Fordham's account of ‘not knowing beforehand’. Some implications for boundaries, enactment and the use of personal disclosure are discussed in relation to clinical material. I compare analysis with the wisdom traditions of religious practice and suggest that analysis is concerned with a way of living rooted in humane values of compassion and benevolence.     

Relational Psychoanalysis and the Inner Life: Commentary on Cooper,Corbett, and Seligman

Relational analysts know that their experience feels private and contemplative during a significant portion of their working hours. A consideration of the inner life, both the analyst’s and the patient’s, is part of relational praxis. Yet relational analysts also recognize that they are continuously involved with their patients, even at those very same quiet moments. Cooper, Corbett, and Seligman recognize both these parts of relational clinical work and argue that both are necessary. Making this argument explicit is important for its own sake, but also because analysts from other schools sometimes write as if there is no place in relational clinical practice for a quiet consideration of the inner life. Two examples of such criticism are offered, in both of which relational analysts are described as being too focused on social interaction and too little on the inner life. I offer my own version of the kinds of arguments about privacy and contemplation offered by Cooper, Corbett, and Seligman. I then make the case that all psychoanalytic theories come with risks of excess. Relational and interpersonal theories come with the risk of an overenthusiastic embrace of clinical interaction, whereas more intrapsychic theories carry the risk of attending too little to the impact on their patients of present-day relatedness—which is just as likely to have unconscious roots as the inner life.     

Life-threatening illness in the analyst

The literature on practicing throughout a life-threatening illness is reviewed and important differences about attitudes toward self-disclosure are understood by noting a division between two perspectives on transference: "one-body" and "two-body" views. The analyst's use of self-disclosure is informed by the prominence given the interpretation of transference as against that given the patient's needs in the collaborative relatedness supporting the therapeutic alliance. Themes and illustrative clinical vignettes are presented from the author's own experience practicing during such an illness. Three phases of working during illness are delineated, each somewhat different regarding the analyst's state, and hence patients' needs and reactions. Recommendations are made regarding conditions that make it possible to work effectively during a life-threatening illness. The analyst needs help from his or her own analyst to make the clinically and sometimes ethically appropriate decisions about practice; while this is important in instances in which the analyst recovers, it is essential should the analyst become terminal and face more certain death.     

The Dream Sense,Emergent Clinical Process,and the Question of Symmetry: Reply to Brown and Colombo

In recent years I have become interested in Bion and neo-Bionian field theory, but the origin of my interest in dreaming does not lie in scholarly or clinical sources. The source of the idea of the dream sense is my own experience. After addressing that point, I reject what appears to be Colombo’s impression (this issue) that detailed inquiry is necessarily the basis of interpersonal and relational clinical practice, and then take issue with Brown’s understanding of expressive participation in relational thinking (this issue). Responding to Brown’s wish that I offer more detail about my own clinical process, I present an overview of my understanding of the way I work. I conclude by addressing the understandings offered by the discussants of symmetry in the analytic relationship, and offering more details of my own.     

Exploring Our “Deltas”: A Training Tool for Conceptualizing Systemic Theory of Change

Systematically utilizing theory to guide clinical practice is integral to developing and maintaining therapist competency. However, helping Marriage and Family therapist trainees develop their own theory of change can be a challenging training component and more educational guides are needed to help facilitate the learning process. This paper introduces the Delta Model for conceptualizing systemic change as such a tool. The proposed Delta Model is introduced and guidelines for specifically teaching trainees at each level of the Delta are provided. The proposed model will be applied to a case vignette and discussion of additional considerations for applying the Delta Model beyond clinical practice will be reviewed.

     

The practice research network: Research into practice,practice into research

The purpose of the broader project on which this report is based was to utilize a Practice Research Network, an alternative to traditional clinical studies to 1) identify demographically one practice group, namely professional counselors in the United States, 2) describe their practice patterns, and 3) identify their client population and the efficacy of their clinical work through client outcomes based on actual client reports. This article describes the development of one such nation‐wide Practice Research Network (PRN) and provides some preliminary findings for each phase of the project. Use of the PRN model can help overcome the traditional “research to practice” gap and provide research results into community practice thus integrating outcomes measures into the daily practice of mental health professionals. During the early phases of this project, a software program was developed upon which the participating practitioners could identify the data elements within the parameters of the focus on their agreed‐upon research interests, enter data following client visits over time, and by comparing their own composite profiles and effectiveness with those of other participating practitioners who had clients presenting with similar diagnoses, could alter their own service delivery patterns, therapeutic interventions, or approaches while working with the clients and thereby improve the efficacy of their service. By participating, the practitioners benefited by access to downloadable and printable reports on profiles of 1) their specific clients, 2) their service delivery patterns, and 3) the outcomes or efficacy by their clients’ direct feedback. They were also able to compare these results with the composite data from other practitioners.     

James Astor in conversation with Warren Colman

In this interview with Warren Colman, James Astor speaks about his development as a Jungian analyst from his own experience of personal analysis in the 1960s to his recent retirement from clinical practice. The discussion covers his long association with Michael Fordham, the child analytic training at the SAP, the infant observation seminars with Fordham and Gianna Henry through which Fordham was able to make new discoveries about infant development, his experience of supervision with Donald Meltzer and the development of his own thinking through a series of papers on the analytic process, supervision and the relation between language and truth. The interview concludes with reflections about the legacy of Michael Fordham and the future of analytic work.