The patient's material as an aid to the disciplined working through of the countertransference and supervision

The author argues that the patient's largely unconscious observations of the analyst's functioning are, at times, communicated in the patient's material and that this can impart a sense of clinical relevance to the countertransference. The concept of 'understanding work' is used to provide a psychoanalytical model of this phenomenon. This is illustrated in a clinical case and it is argued that a selective consideration of the patient's material can provide a proper discipline which steers the analyst between the twin dangers of megalomania, on the one hand, and involvement in a symmetrical, self-disclosing relationship, on the other. The author then applies these ideas to supervision and uses them to distinguish psychoanalytic supervision from a practice that also derives from an intersubjective paradigm but which, to the author's mind, is not distinct enough from personal analysis.     

The analyst's theory: A third source of countertransference

The author asserts that the analyst's theory, personal and/or academic, is an important source of countertransference which complicates our traditional understanding of the analyst's emotional responses as being constructed from a mix of his transferences and the patient's effects on him. From this perspective, theory - because it has no intrinsic relevance to the essential phenomena of individual analytic processes - may be a confounding, as well as a necessary, factor in clinical work. Although the analyst's theory might be conceptualized as a component of his personality that shapes his emotional reactions to a patient, the author believes that there is a valuable increment of conceptual clarity and additional clinical utility to thinking about a more direct role of theory in the process of countertransference formation. He uses aspects of the clinical analysis of narcissistic resistances to illustrate how some theories might predispose an analyst to confounding unconscious enactments by generating either positive or negative countertransferences which can be used defensively by the patient and/or analyst. He also illustrates how, in some contexts, an analyst's theory might attenuate potentially informative countertransference reactions and interfere in this way with the analyst's apprehension of the patient's psychic functioning. Finally the author addresses the importance of 'fit' between an analyst's working theory and a patient's psychopathology, and considers implications of his ideas for psychoanalytic training and practice.     

When words fail: psychosomatic illness and the talking cure

This paper discusses psychosomatic illness as a disorder of the individual's subjectivity in relation, or a surrender of mind and mindfulness to the other. Illustrative clinical material highlights the usefulness of Harry Stack Sullivan's (I954) detailed inquiry in locating the psychosomatic patient's own voice in the consulting room. Particular attention is paid to the form and use of language to impede or foster private experience and personal agency.     

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.     

Playing one's cards face up in analysis: an approach to the problem of self-disclosure

A policy of consistent willingness on the analyst's part to make his or her own views explicitly available to the patient is discussed and illustrated by clinical vignettes. Playing one's cards face up is contrasted with contemporary conceptions of selective self-disclosure by the analyst, especially with respect to the way ground rules for the analytic treatment relationship get established. The objective of the analyst playing his or her cards face up is to create a candid dialogue, thus facilitating maximally effective collaboration between analyst and patient. Concerns about the analyst's self-disclosure foreclosing exploration of the patient's unconscious fantasies and transferences, or intruding upon the patient's autonomy, are addressed, as is the relation between self-disclosure and an individual analyst's personal style.     

The egg, the vessels and the words. From Izdubar to answer to job for an imaging thinking

This essay on The Red Book seeks to underscore a characteristic specific to Jung's approach to psychoanalysis. In this book, and more generally, in all of his writings, Jung's thinking is based on his personal experience of the unconscious, in which he leaves himself open to progressive encounters. Some of them, in the years 1913-14 and 1929-30, particularly his meeting with the giant Izdubar, were quite threatening. As a result, he forged an original way of thinking that is qualified here as 'imaging' and 'emergent'. The Red Book served as the first vessel for theories Jung would later express. His way of thinking, with its failures and semi-successes, all of which are always temporary, of course, is compared to the art of the potter. The author shows the kinship between the formation of the main Jungian concepts and the teachings of the French poet, professor, and art critic Yves Bonnefoy. He also considers certain recurrent formal themes in the work of contemporary German painter and sculptor Anselm Kiefer. Lastly, this epistemological study, constantly aware of the demands of Jungian clinical practice, demonstrates the continuity in Jung's work, from The Red Book to Answer to Job, where Jung ultimately elaborated a conception of history that defines our ethical position today.     

PSYCHOANALYTICAL PSYCHOTHERAPY: Death in the afternoon

One afternoon, a patient who had been in three-times-weekly psychoanalytic psychotherapy for over fi ve years with the author left the offi ce after her session, drove down to the train tracks half a mile away, and sat down facing an oncoming train. Her suicide occurred a little over a year after 19 hijackers took over four passenger airplanes and fl ew two of them into the World Trade Center, and during the period of the massive buildup for a pre-emptive war with Iraq. This paper explores the very personal impact of these interlocking events of personal, political, and state-sponsored terrorism on the author. Interweaving the patient's and the author's personal struggle with the patient's overwhelming destructiveness-and how it ultimately failed-with the inability to stop the war despite the unprecedented mobilization of voices for peace across the world, it is a journey through the shattering impact of violence into the tentative discovery of a sustaining vision of hope. It explores the theme of terrorism, both personal and political, as a theater of violence designed to create maximum impact, and how fantasies of redemption, fueled and blinded by righteous certainty, can transmute into acts of breathtaking violence, and fi nd justifi cation in their own mad logic. Through the elaboration of the patient's story and its impact on the author, she offers a very personal attempt to understand and reckon with violence and destructiveness as manifested in these different forms, to grasp how openings of hope and new creative possibility are often followed by a violent regressive backlash, and to fi nd a way to survive them without losing heart for the work.     

On a soma-psychotic part of the personality: a clinical and theoretical approach to the somatic

Inspired by Bion, the concept of a soma-psychotic part of the personality is suggested. The authors present four clinical vignettes to illustrate certain clinical phenomena in which the body played a key role in the patient's personal history, during the analytic process, or both. Certain aspects of analytic technique with these severely disturbed patients are briefly referred to, including the analyst's reverie and transformational capacity, and some observations made in these cases lead to tentative generalizations on mental functioning and psychosomatic unity. A theoretical model is constructed to contain both data and conclusions, and to offer a solution for the integration of the somatic in psychoanalytic theory.     

Diabetes mellitus as a model of psychosomatic and somatopsychic interrelationships

The article reviews research on the problem of interrelationship between different physical and psychosocial factors in type 1 diabetes mellitus (DM1). The authors consider methodological principles of health-related quality of life (HRQoL) assessment in DM1 patients and stress the need for an integrated biopsychosocial approach to the management of the disease. DM1 is a chronic metabolic disease with an absolute requirement for insulin replacement therapy. The stress-inducing nature of DM1 is associated with its unexpected and dramatic manifestation in juvenile years, life-threatening nature of severe hypo-/hyperglycaemias and long-term complications, with the burden of diabetes self-management, threat of work disability, employment and career problems etc. These features of DM1 increase the likelihood of the development of anxiety and depressive disorders, which, in turn, may negatively influence the course of diabetes and in particular, diabetes self-care. This necessitates early diagnosis of emotional and behavioral disturbances in DM1 using self-report instruments as well as clinical assessment. Evidence suggests that active problem-focused coping behavior and adequate social support promote adherence to diabetes regimes and may act as a buffer against negative effects of the disease on HRQoL in DM1 patients. The core element in the HRQoL structure is personal disease picture (as opposed by objective clinical picture)--the cognitive-affective-behavioral complex reflecting the patient's personal perception of the disease. Examination of the personal disease picture and attitude towards the ailment in DM1 patients may help to improve understanding of the mechanisms of poor adjustment. Problems in disease adjustment can be detected also by diabetes-specific HRQoL assessment. The measures of HRQoL can be applied as screening instruments useful in increasing the effectiveness of patient-provider interactions and diabetes care.     

What does the child analyst bring to Jungian thought?

The author wants to show the influence that the historical acknowledgement of child therapy at the Jerusalem IAAP Congress in 1983 has had today on the Jungian world, especially on the clinical approach to their patients by analysts working only with adult patients. If her conclusions do not allow her to dissociate the strong influence on psychoanalysis of contemporary research on attachment theory and mother-child relationship from a specific Jungian child therapists' perspective, she points out, through three examples from Jungian literature, how the need for a metapsychology of development and the study of primary and personal aspects of the patient's life are explicit in the work and research of analysts working with adults.     

Disturbed sense of identity in borderline personality disorder

Traditionally, personal identity is considered to be important for psychological health and adaptive functioning. Identity diffusion and other more severe forms of disturbance associated with personal identity are regarded as being essential parts of the borderline personality disorder. Moreover, disturbances in identity are seen as being part of the dynamic background for many of the symptoms and maladaptive behaviors found in borderline patients. It is argued, that the development of personal identity is intimately related to, and indeed dependent on, elements of modern culture, with significant cultural changes having affected the conditions under which human identity develops. Therefore, the identity diffusion seen in patients with borderline disorders must be understood in relation to not only the individual patient's personal history and inner structures but also contemporary late modern culture and social organization.     

Some images of the analyst's participation in the analytic process

This paper was originally presented at a workshop (with G. Atwood and S. Parks) on The analyst's participation in the analytic process'. The analyst's 'vulnerability' is highlighted, with specific reference to the ideas of Winnicott, Searles and Jung. Some personal metaphors for the nature of the analytic engagement are offered, as is the image of the 'troubled analyst' from a patient's dream. The burden and necessity of the analyst's participation are emphasized.     

Patient's surface, clinical surface, and workable surface

Surface is a term often used in clinical theory, which seems to have eluded a reliable definition. Freud used the term mostly to denote the analysand's consciousness. This patient's surface does not always coincide with the data the analyst can observe, i.e., the clinical surface. It is proposed that clinical surface be understood, in contrast to other psychoanalytic concepts, as the clinical evidence that does not need conjecture to be grasped cognitively. The concept of "average expectable apperception" is introduced. Workable surface is defined as those aspects of the clinical surface that lend themselves well to the exploration of unconscious dynamics or genesis. Ideas about which surfaces are optimally workable vary according to different schools of technique. The advantages of considering clinical surface the objective anchorage of psychoanalysis as a positive science and of differentiating it from patient's surface and workable surface are discussed.     

消费情感、公平感与患者满意感

消费情感是顾客对交易过程是否公平的情感性体验,公平感是顾客满意感形成的基础条件。在医疗服务消费过程中,患者满意感不仅是对医疗效果是否符合其预期的主观评价,而且也是对医疗服务消费过程中诸如服务行为方式、操作程序规范以及经济利益交换等环节的情感认知性反应。     

The Red Book from a pre-modern perspective: the position of the ego, sacrifice and the dead

This paper tries to investigate The Red Book from a pre-modern point of view especially with reference to a Japanese cultural and clinical perspective. In spite of overwhelming contents from the unconscious, the position of the ego is remarkable as a formal aspect throughout The Red Book. The ego manifests itself as a stable observing agency which results in clear images. In the case of Japan, visions are historically rare because of the much more vague position of the ego. While in Liber Primus the ego manifests itself via suffering and tragedy, in Liber Secundus it has more distance and humour, and takes the form of comedy. Mythological images are internalized as fantasy in Liber Secundus. So the rebirth of God does not need to be performed literally but by way of internalization, which is the origin of Jungian psychology. In its substantial aspect, the references in The Red Book to pre-modern cultural images of sacrifice and redemption of the dead are impressive. The sacrifice may suggest that the numinous cannot be experienced as ritual and symbol but necessitates direct violence and sexuality.     

Appraisals of control and predictability in adapting to a chronic disease

In a sample of 92 patients with rheumatoid arthritis, we examined interrelations among various control appraisals, illness predictability, psychosocial adjustment, mood, and illness status. Perceiving greater personal control over the disease and symptoms and perceiving greater health-care-provider control over symptoms were associated with greater illness predictability. Patients reported more personal control over their symptoms than over the course of the disease and thought that their health care providers had more control over disease course than they did themselves. Multiple regression analyses showed that perceiving greater personal control over one's medical care and treatment was associated with positive mood and psychosocial adjustment. Negative mood was also associated with the belief that providers have greater control over the patient's daily symptoms. Patients who had a more severe disease and expressed greater personal control over its course reported greater mood disturbance and were rated as exhibiting less positive adjustment, but those who had more severe daily symptoms and expressed greater personal control over their symptoms reported less mood disturbance. These findings are discussed in terms of the possible benefits of patients' active participation in their care and the implications of perceiving personal and others' control over more or less controllable aspects of the illness, especially when the illness is more severe.     

Employing multiple theories and evoking new ideas: the use of clinical material

In this paper, I wish to illustrate how working with a patient who had a certain kind of narcissistic difficulty led me to develop particular clinical strategies to facilitate the development of a sturdier sense of self, greater affect tolerance and modulation, the diminution of harshness of her superego, and the ownership of projected parts of herself, and to decrease paranoid ideation. I call upon concepts from various theoretical schools of psychoanalysis to make sense of the dynamic intricacies of the patient's psychological organization as they revealed themselves in the analytic process. These conceptualizations of the patient's difficulties and of clinical interventions to address them result in a hybrid theory of both theory and technique. What transpired in the clinical work also led me to propose an additional way to understand this kind of patient's difficulties with accepting interpretations or any view that differed from the patient's subjectivity. I am proposing that 'otherness' itself, rather than only specific conflictual aspects of the self, is disowned. It is the analyst's empathic stance toward all that is repudiated--the specific disowned aspects of the self and 'otherness' itself--along with empathy for the patient's conscious state that will enable reinternalization and ultimately healing.     

Personal Identity, Autonomy and Advance Statements

abstract    Recent legal rulings concerning the status of advance statements have raised interest in the topic but failed to provide any definitive general guidelines for their enforcement. I examine arguments used to justify the moral authority of such statements. The fundamental ethical issue I am concerned with is how accounts of personal identity underpin our account of moral authority through the connection between personal identity and autonomy. I focus on how recent Animalist accounts of personal identity initially appear to provide a sound basis for extending the moral autonomy of an individual — and hence their autonomous wishes expressed through an advance statement — past the point of severe psychological decline. I argue that neither the traditional psychological account nor the more recent Animalist account of personal identity manage to provide a sufficient basis for extending our moral autonomy past the point of incapacity or incompetence. I briefly explore how analogies to similar areas in law designed to facilitate autonomous decision, such as wills and trusts, provide at best only very limited scope for an alternative justification for granting advance statements any legal or moral authority. I conclude that whilst advance statements play a useful role in formulating what treatment is in a patient's best interests, such statements do not ultimately have sufficient moral force to take precedence over paternalistic best interests judgements concerning an individual's care or treatment.     

A comprehensive and concise assessment of suicide risk

Because suicide is one of the few fatal consequences of psychiatric illness and is a source of extraordinary stress for loved ones and the clinician, accurate assessment of suicidal risk is an essential aspect of the mental health profession. Innumerable individual differences, along with the low base rate of suicide, make assessment a challenging task in clinical practice that is both delicate and time consuming. In this article, the authors recommend examining and incorporating each patient's personal characteristics, dispositional factors, situational factors, and current presentation of symptoms into a unique individual picture of suicidal risk. This portrait of potential for suicidal behavior can, in turn, be used to evaluate risk and design a course of action. This thorough yet concise approach will likely reduce omissions in assessment, and hopefully lead to fewer false negatives and fewer deaths of suicidal patients.