Being, thinking, creating: when war attacks the setting and the transference counter-attacks

When trauma enters into the reality of the analyst and of the analysand, when it attacks the setting, what becomes of the analyst’s role? How can transformations be brought about? With reference to three clinical situations, the author attempts to explore how the articulation between transference and countertransference – the inter‐relation – structures the situation; the analyst must remain in his or her role as analyst through managing to create and to reflect upon the clinical aspects of that situation when faced with the unpredictability of what war brings in its wake. It then becomes possible to see how the work of the negative can be confined to the outer limits of the setting.     

Confidentiality, privacy, and the facilitating role of psychoanalytic organizations

Burgeoning external threats to confidentiality by claims to clinical information create unprecedented challenges for psychoanalysts. Internal threats arise from the use of clinical material for educational, scientific and historical purposes. Traditionally, confidentiality is considered a patient's right and an analyst's obligation; privacy is not usually stated as a professional requirement. Little consideration has been given to the impact of the confidentiality and privacy dilemmas that analysts encounter throughout their careers. There has been no systematic examination of the confidentiality policies of psychoanalytic organizations, nor has their role in facilitating maintenance of patient confidentiality and analysts' privacy been made explicit. The research reported here was undertaken to address these issues and to obtain baseline information about the current confidentiality policies and practices of psychoanalytic organizations in three English-speaking countries (Britain, Canada and the USA). The author discusses survey results in the light of the challenges which arise at each phase of the analytic career. She makes suggestions as to how psychoanalytic organizations can and should facilitate analysts' resolutions of contemporary confidentiality and privacy dilemmas.     

Reconstruing the "reconstruction" of psychopathy: a comment on Cooke, Michie, Hart, and Clark

In this comment we highlight critical problems in the estimation of parameters for their hierarchical three-factor model of psychopathy, as assessed with the Hare Psychopathy Checklist, and their interpretation of these factors as causally related to socially deviant behavior. We argue that there is nothing "causal" about a model in which cross-sectional data are used to assert that antisocial tendencies are consequences of other more fundamental psychopathic traits. We present an equally viable model, based on the PCL-R four-factor solution, in which antisocial tendencies play a fundamental role in the construct of psychopathy, consistent with previous research and clinical tradition.     

Beauty,ugliness and the sublime

Jung and Freud had very different ideas about the nature of analysis. This paper begins by exploring how Jung's gnostic approach, with its goal of individuation, is deeply informed by Buddhist and Taoist principles. His pluralistic, relational model regards truth as subjective and co‐constructed with the patient. In contrast, Freud's secular methodology has objective truth as its goal. His classical psychoanalysis is a form of reality testing where the analyst claims to know the painful, singular, objective reality which the patient tries to evade. The theory of aesthetic development (see Piaget 1951, Baldwin 1975, Parsons 1980, Housen 1992, Harris Williams 2010) proposes that artistic appreciation is linked to human development. The paper looks at how the apperception of beauty, related to both truth and meaning, acts as an indicator and facilitator of individuation in the clinical encounter. This is illustrated by a clinical case study. Through empirical research, support is given to the argument (Bollas 1978, Meltzer 1988) that our early experience of the feminine/maternal plays a central role in developing an aesthetic capacity. The experience of the sublime in analysis is examined and portrayed as a means by which aesthetic development may be reignited and narcissistic isolation shattered.     

The partnership between the Early Intervention Institute,St Petersburg,and the Anna Freud Centre,London

The authors describe study and teaching links between the Early Intervention Institute in St Petersburg and the Anna Freud Clinic in London. Some brief clinical examples from a variety of settings are given as well as a longer case presentation. The impact of widespread institutional care, alcoholism and terrible housing conditions on child mental health are illustrated. This raises questions about the role of child psychotherapy when social conditions are so harsh. The case material indicates that, despite this, children can be helped in some measure to feel more secure, by the therapist providing constancy and reliability within an often frightening and dangerous external world.     

Narrative process modes as a bridging concept for the theory, research and clinical practice of systemic therapy

This article is concerned with the relationships which hold between the clinical practice and the theory of family therapy; and between these and academic research. These relationships are seen as tenuous and thin because, in the first place, there is a lack of rigorous theoretical underpinning; and second, the research methods employed do not fit in with current family therapy practice, and with the theory that underlies this practice. The role of the concept of narrative process modes is proposed as a bridging and mediating one. The external, internal and reflective narrative process modes are seen as relevant from the point of view of family therapy process research, and the clinical practice of marital and family therapy.     

On Knowing and Using Myself: Reflections on an Analyst's Subjectivity,Intersubjectivity, and Psychoanalytic Change

In this article I describe my journey to become a psychoanalyst, which includes discovering my resonance with the ideas and clinical approaches of a contemporary self psychological relational approach. I also reflect on a clinical vignette that I see playing a crucial role in my development as a psychoanalyst and consider analytic change processes in both implicit and explicit realms.     

The effects of stressful life events,coping, and cortisol on HIV infection

What is the role of stress and coping in changes in immunologic and clinical indicators of human immunodeficiency virus disease progression? There is substantial evidence that stressful life events and passive coping strategies, such as denial, may have a detrimental effect on HIV disease progression. Given the harmful effects of stress and passive coping, the author reviews the limited research testing the efficacy of interventions, such as cognitive-behavioral therapies for HIV-infected persons. Finally, in trying to understand psychoimmune relationships in HIV, the evidence is examined for the mediating and direct effects of cortisol, a hormone associated with stress, on HIV disease progression. Delineating the role of psychosocial factors and cortisol on HIV disease progression may aid in the development of new interventions for this devastating disease.     

Consulting the Many and the Wise

Conceived as a solution to clinical dilemmas, and now required by organizations for hospital accreditation, ethics committees have been subject only to small-scale studies. The wide use of ethics committees and the diverse roles they play compel study. In 1999 the University of Pennsylvania Ethics Committee Research Group (ECRG) completed the first national survey of the presence, composition, and activities of U.S. healthcare ethics committees (HECs). Ethics committees are relatively young, on average seven years in operation. Eighty-six percent of ethics committees report that they play a role in ongoing clinical decision making through clinical ethics consultation. All are engaged in developing institutional clinical policy. Although 4.5% of HECs write policy on managed care, 50% of HEC chairs feel inadequately prepared to address managed care. The power and activity of ethics committees parallels the composition of those committees and the relationship of members to their institutions. The role of ethics committees across the nation in making policies about clinical care is greater than was known, and ethics committees will likely continue to play an important role in the debate and resolution of clinical cases and clinical policies.     

Choice,the Invisible Element in Our Work

Unless they use a highly structured approach, psychotherapists make choices all the time in their work, but the role of choice is neglected in the professional literature. Because choices tend to issue under the radar, sometimes as personal enactments, our profession could benefit from examining them. This is especially true for leaders of therapy groups where there are pressures to align with conventional perspectives of pathology, of popular “goodness” and “badness.” Two important influences on our decisions here are milieu—the historical period in which we work—and our clinical identity (training, personality, identifications and practical experience). It is to reinforce these that we often make our choices.     

Teaching ethics on rounds: The ethicist as teacher,consultant, and decision-maker

This paper explores the relationship between teaching and consulting in clinical ethics teaching and the role of the ethics teacher in clinical decision-making. Three roles of the clinical ethics teacher are discussed and illustrated with examples from the authors' experience. Two models of the ethics consultant are contrasted, with an argument presented for the ethics consultant as decision facilitator. A concluding section points to some of the challenges of clinical ethics teaching.     

Effecting science, affecting medicine: homosexuality, the Kinsey reports, and the contested boundaries of psychopathology in the United States, 1948-1965

Despite the well-documented intensive battle between Alfred Kinsey and American psychiatrists around the mid-twentieth century, this paper argues that Kinsey's work, in fact, played a significant role in transforming mental health experts' view of homosexuality starting as far back as the late 1940s and extending all the way through the mid-1960s. After analyzing the way in which Kinsey's work pushed American psychiatrists to re-evaluate their understanding of homosexuality indirectly through the effort of clinical psychologists, I then focus to a greater extent on examples that illustrate how the Kinsey reports directly influenced members of the psychiatric community. In the conclusion, using a Foucauldian conception of "discourse," I propose that in order to approach the struggle around the pathological status of homosexuality in the 1950s and the 1960s, thinking in terms of a "politics of knowledge" is more promising than simply in terms of a "politics of diagnosis." Central to the struggle was not merely the matter of medical diagnosis, but larger issues regarding the production of knowledge at an intersection of science and medicine where the parameters of psychopathology were disputed in the context of mid-twentieth-century United States.     

Self-Psychology,Shame, and Adolescent Suicide: Theoretical and Practical Considerations

Using the psychoanalytic self-psychology of Heinz Kohut as the theoretical foundation of this article, the authors discuss the role of shame in adolescent suicidal behaviors. Shame is described as a central component of suicidal behavior within the context of adolescence, a fundamental stage in the development of the healthy self. Normal and pathological self-development are described and important issues pertaining to the development of the self during adolescence are explored. A theoretical explanation of adolescent suicidal behavior from a self-psychology perspective is offered. Finally, suggestions for treatment of the suicidal adolescent and an illustrative clinical vignette are presented.     

Sex Differences,Sex Roles,and Projection on the TAT: Matching Stimulus to Examinee Gender

We examined the assumption that on the Thematic Apperception Test (TAT) examinees identify more with stimulus characters of the same sex as themselves and therefore produce more projective material when tested with these gender matched cards. Repeated measures analyses of variance and t tests showed no increase in projection as a result of matching gender or sex role of subject to card stimulus. Results do not support the clinical utility of the separate male and female sets of TAT cards.     

The language of empathy: an analysis of its constitution, development, and role in psychoanalytic listening

Viewed from an epistemological perspective, empathy in psychoanalytic practice is described as that aspect of a specialized attentional stance that opens channels of interaction facilitating the formation of a trusting bond and enabling one to gain access to the emotional qualities of another's experience. A literature overview traces the origins of the concept in Freud and its role in psychoanalytic listening (including its controversial, divisive evolution in our field). Empathy is then examined from a semiotic-developmental framework. Its constitutional origins, differentiated forms, and distinctive purpose in clinical discourse are discussed. A developmental line is proposed, and clear distinctions are drawn between empathy in everyday life and its specialized technical application in clinical work.     

Creating analysts, creating analytic patients

This paper applies a contemporary, 'two-track'- transformational as well as archaeological - perspective on psychoanalytic process to clinical issues in the creation of analytic patients: case finding, recommending analysis, and recommending and negotiating the intensification of frequency of sessions in analytic psychotherapy. Central importance is assigned to the role of the mind and analytic identity of the analyst, including the analyst's capacity to maintain an internal analytic frame and analyzing attitude from the very first contact with the patient and throughout the treatment, the analyst's confidence in and conviction about the usefulness of analysis for a given analytic dyad and the role of the analyst's theory, which must be broad and consistent enough to allow the analyst to feel that he or she is operating analytically when addressing non-neurotic (unrepresented and weakly represented mental states) as well as neurotic structures.     

Working Together,We Get the Job Done: Responses to Susan Bodnar and Philip Cushman

In his response, Samuels argues that the issues under discussion are more of a work in progress than Bodnar claims and that therapists are more accurately perceived of as construction workers than the philosophers and theorists that Cushman wants them to be. More detail is given on working with political material in the session. Economics is presented as a field for exploration in therapy. Certain philosophers are cited for their relevance to clinical work. Theory as bricolage is suggested. Further material on the role of the arts in connection with progressive therapy practice is introduced. Questions of language are discussed.     

"I had twenty-five piercings and pink hair when . . .": adolescence, transitional hysteria, and the process of subjectivization

The author discusses adolescent and preadolescent development as a transformative experience. The role of the ego ideal in this process, as distinct from the ideal of the ego, is highlighted, and idealization, narcissism, and symbolization are also discussed. Changing representations contribute to what the author describes as a process of subjectivization. An illustrative clinical vignette is presented: that of a 12-year-old girl who developed neurological symptomatology during a crucial period of psychosexual transformation, and whose symptoms rapidly receded after only a few psychoanalytically oriented treatment sessions. The author emphasizes his view of preadolescence as an important passage for the individual's knowledge of the plurality that characterizes him, noting that the recognition of one's own internal multiplicity is characteristic of the psychoanalytic process.     

Phantasies, Neurotic-Beliefs, and Beliefs-Proper

This paper presents a philosophical analysis of three cognitive states familiar and important to psychoanalysts—phantasy, neurotic-belief, and belief-proper. It explores the differences among these three propositional attitudes and finds that the development of secondary process capacities of reality testing and truth directness out of earlier primary process operations (themselves prior to considerations of truth or falsity) plays a crucial role. Difficulties in the proper typing of cognitive states are discussed, as are the consequences of such confounds. This use of a philosophical method serves to sharpen the familiar psychoanalytic clinical concepts of phantasy and neurotic-belief. In addition, these same clinical concepts, once properly specified, have much to offer the philosophy of mind, where current understanding of representational cognitive states is restricted to those that are largely conscious and rational. When psychoanalytic concepts such as phantasy and neurotic-belief can be better integrated within the discipline of philosophy of mind, both philosophers and psychoanalysts will have a more complete and adequate theory of mind.