Being with a psychotic child a psycho-analytical approach to the problems of parents of psychotic children.

The reactive and adaptive responses of parents to their overtly psychotic children are described and an attempt is made to reconstruct the specific mother/infant interactions contributing to the development of different types of childhood psychosis. The concepts of 'maternal structure' and of 'delusional primary maternal preoccupation' are found to be relevant in this context. These considerations throw light on some aspects of countertransference encountered by workers in this field and of creative search in general. Whilst exploring parental psychology and psychopathology this paper attempts to outline the psychodynamic environment of the psychotic child at the various stages of his life and dis-ease. It emphasizes the value of the psychoanalytical approach as a guide in such an exploration and as a source of hope for better understanding and more effective interventions, both therapeutic and prophylactic.     

Transference with the borderline client

This paper addresses the question of what is involved in psychodynamic counselling with borderline clients. The concept of borderline functioning or structure is explained and the technical difficulties of working in this area noted, especially in the establishment of a working alliance. The types of transference manifestations with borderline clients are then described, looking in particular at the emergence of a psychotic transference. Two case examples are given of working with borderline clients, where the transference was dominated by primitive elements, provoking powerful countertransference reactions in the counsellor. How both the client and the counsellor can be contained in the therapeutic work is then addressed. Finally, some implications of this discussion are drawn out for the training of psychodynamic counsellors, in order to equip them best for working with borderline clients. Three features of what a training should offer are identified: it should provide students with the opportunity for the exploration of the psychotic parts of their own personality; it should allow for and encourage the internalization of psychoanalysis itself as a sustaining internal object; and it should provide students with the experience of working with clients over sufficient time and at sufficient depth so they can learn about the timing and effectiveness of interventions in work with borderline clients.     

Psychodynamik und Psychotherapie psychotischer St?rungen

This article gives a review of the options for psychodynamic treatment of patients with psychoses. The various settings for individual treatment as well as group and family therapy will be presented with a special emphasis on modified analytical long-term therapy. For a psychodynamic understanding, which is the basis for this treatment, the most important psychoanalytical models for psychotic disorders will be presented. In addition the current empirical results of non-explicit psychodynamic-oriented research will be referred to, which emphasize the significance of traumatic events in the early phases of life and the importance of narrative elements, whereby the psychodynamic approach experiences both complementation and confirmation.     

Hysteria and psychosis

The relationship between endogenous-psychotic and hysterical behavior is presented in this paper on the basis of typical patients' accounts. Various patterns of behavior are revealed: chronic hysterical psychotic syndromes, acute hysterical psychotic syndromes, hysterical exalted psychotic episodes, simulated hysterical psychotic syndromes, hysterical behavior in the attempt to cope with psychosis, and pseudohysterical behavior in endogenous psychoses. The specific aspects of the doctor-patient relationship in the case of these patients are described.     

Mentalization-Based Interventions in Child Psychiatry and Youth Protection Services I: Objectives,Setting, General Principles and Strategies

ABSTRACT

Many of the children who receive services in child psychiatry or are in the care of Youth Protection Services present with complex, multiple and often severe problems. Classic psychodynamic psychotherapy seems to be of little benefit to them. The majority of these children tend to not use symbolic play as a means of expressing their intrapsychic conflicts or relational difficulties and they do not verbally communicate much with clinicians. They are more likely to display an imaginative poverty that translates into boredom, motor discharge, and an inability to use the material put at their disposal for therapeutic purposes. The systematic and rigorous observations of these children in Quebec revealed that the majority of them present with severe mentalizing difficulties. They often show attitudes and behaviors linked to the prementalizing modes of psychic functioning. This article presents a mentalization-based intervention adapted to these children’s difficulties. The objectives, adaptation of the work setting, and general principles underlying this intervention are discussed. In addition, general intervention strategies are also covered. These interventions are considered as preparatory work whose principal purpose is to enable children to benefit later on from psychodynamic psychotherapy. The authors also recommend specific intervention strategies adapted to children’s predominant mode of psychic functioning. The details of these strategies will be shared in a separate article.     

Psychotherapie der Psychosen

In this paper the psychotherapy of patients with schizophrenic, schizoaffective and affective psychoses is outlined. Psychoanalytic, cognitive-behavioural and systemic approaches and their theoretical concepts as well as the therapeutic techniques are de- scribed. The settings of individual, group and family therapy are also presented. A survey of the types of psychoanalytic therapy with their eldest historic roots is given with the development of the various psychodynamic concepts for schizophrenic and affective psychoses including schizoaffective psycho-ses. The different kinds of psychotherapy are compared to each other with respect to the aims. Finally this paper deals with the effectiveness of the therapies and discusses the pros and cons of relatively short randomised controlled trials compared with long term psychotherapies without control groups.     

Psychosis,symbol, affectivity 1: etiopathogenesis and treatment through analytical psychology

This is the first of two papers concerning our study into an integrated approach to psychotic disorders, conducted at the University of Palermo’s Psychiatry Unit Polyclinic over approximately 15 years. Here we will explore and reflect upon the acute psychotic condition mainly from a theoretical and conceptual perspective, while in the second paper we will explore the clinical perspective. From the point of view of psychopathology, and in the light of C.G. Jung’s conceptualization of analytical psychology, as well as calling on contributions from other authors from the systemic-relational and post-psychoanalytic field, we will clarify the ideas developed over these last few years by our team. From a more speculative perspective we will advance new interpretive hypotheses in an attempt to thoroughly understand the nature of the psychotic condition, both on a psychodynamic relational and a neuroscientific level. The paper describes how we revised our understanding of psychosis from a brain disease to a process aimed at the rearrangement of psychic functioning, as anticipated by John Weir Perry nearly 40 years ago.     

How a therapist survives the suicide of a patient—with a special focus on patients with psychosis

The article draws from a personal clinical experience of two suicides, not far removed from each other in time. The first patient was a 33-year-old intellectual suffering from depression with narcissistic traits but no psychotic elements, while the second patient was a 21-year-old student with a manifest psychotic episode behind him and with characteristics of post-psychotic depression at the time of suicide. The two suicides had very different impacts on the therapist: the first left open some “space” for reflection, communication, and working-through, while the second closed such a “space,” leaving only a tiny door to the existential roots of human beings and suffering. The therapist was able to find some “shelter” by talking to supervisors, colleagues, and friends in the first case; in the second, the only possible “shelter” was glimpsed in the philosophy of groundlessness (Ungrund) of the Russian existentialist Nicolai Berdyaev. The personal experiences of the therapist, along with some theoretical interpretations of the after-effects of both suicides, are presented using a psychodynamic and existential–phenomenological understanding of the therapeutic relationship with a psychotic and a non-psychotic patient. The main dilemmas exposed by a patient’s suicide, especially if the patient suffers from psychosis, are difficult to deal with in the usual clinical settings and call for resources beyond it. The authors propose that these can be found in philosophical and theological insights.     

Psychoanalytic Considerations Regarding the Occupational Therapy Setting for Treatment of the Psychotic Patient

Occupational therapists have always been concerned with the treatment of the psychotic patient. Oddly enough, the traditional setting offered to these patients in occupational therapy has not been the object of too much thought or consideration. In order to attain a therapeutic process, the therapeutic setting must be defined furst. The need for such a measure appears essential in therapy with the psychotic patient since his/her own internal structure is impaired. To understand fully the process of the therapy one must take a look at the impact of all dimensions of the setting. This paper discusses the psychodynamic consequences of the setting in occupational therapy in the treatment of psychotic patients.     

Counsellors' experiences of changing their practice: Learning the psychodynamic‐interpersonal model of therapy

Seven counsellors were interviewed about their experiences of learning and applying a new approach to therapy: the psychodynamic‐interpersonal model. These interviews were analysed using grounded theory — a qualitative approach. Under the core category of ‘changing counselling practice: applying the PI model of therapy’, the material was organised into 10 major categories: difficult feelings; new awareness; therapeutic identity; identifying reasons for choosing how to work; experiencing difficulties in adherence; attributing causes of difficulties; ways through the difficulties; understanding how change in practice occurs; changing interventions; and specific other inputs. Examples from the interviews are used to cast light on the difficulties experienced by counsellors in the process of changing their practice.     

Are psychodynamic and psychoanalytic therapies effective?: A review of empirical data

There is a need for empirical outcome research in psychodynamic and psychoanalytic therapy. However, both the approach of empirically supported therapies (EST) and the procedures of evidence‐based medicine (EBM) have severe limitations making randomised controlled trials (RCTs) an absolute standard. After a critical discussion of this approach, the author reviews the empirical evidence for the efficacy of psychodynamic psychotherapy in specific psychiatric disorders. The review aims to identify for which psychiatric disorders RCTs of specific models of psychodynamic psychotherapy are available and for which they are lacking, thus providing a basis for planning further research. In addition, results of process research of psychodynamic psychotherapy are presented. As the methodology of RCTs is not appropriate for psychoanalytic therapy, effectiveness studies of psychoanalytic therapy are reviewed as well. Studies of psychodynamic psychotherapy published between 1960 and 2004 were identifed by a computerised search using Medline, PsycINFO and Current Contents. In addition, textbooks and journal articles were used. Twenty‐two RCTs were identifed of which 64% had not been included in the 1998 report by Chambless and Hollon. According to the results, for the following psychiatric disorders at least one RCT providing evidence for the efficacy of psychodynamic psychotherapy was identifed: depressive disorders (4 RCTs), anxiety disorders (1 RCT), post‐traumatic stress disorder (1 RCT), somatoform disorder (4 RCTs), bulimia nervosa (3 RCTs), anorexia nervosa (2 RCTs), borderline personality disorder (2 RCTs), Cluster C personality disorder (1 RCT), and substance‐related disorders (4 RCTs). According to results of process research, outcome in psychodynamic psychotherapy is related to the competent delivery of therapeutic techniques and to the development of a therapeutic alliance. With regard to psychoanalytic therapy, controlled quasi‐experimental effectiveness studies provide evidence that psychoanalytic therapy is (1) more effective than no treatment or treatment as usual, and (2) more effective than shorter forms of psychodynamic therapy. Conclusions are drawn for future research.     

Studies of higher nervous activity in functional psychoses

Psychiatric illnesses can be conceived of as experiments of nature, providing a variety of pathopsychological mechanisms which may elucidate normal psychological processes. Clinically the reactive psychoses are predominantly psychogenic reaction types. They present disturbances of higher nervous activity, similar to those of the neuroses. The unconditional reflex activity is practically as in normal controls, and the most outstanding finding was the large effect of psychodynamic complex structures. This is a physiological parallel to the clinical manifestations with great concern over experienced mental trauma. In the manic-depressive psychoses the most characteristic feature is a marked disturbance of unconditional reflex activity. This factor may be an important physiological mechanism underlying the more biological than psychodynamic reaction type and partly explain the changes of mood and associated interferences with sleep, body weight, sexual activity, aggression and other instinctual and vegetative functions. Schizophrenic psychoses also present changes of unconditional reflex activity, predominantly in the direction of inhibition of response. In addition there are severe dissociations within and between the three levels of unconditional reflexes and the two signaling systems. It is suggested that schizophrenia represents a functional maladaptation, which can be explained from the principles of autokinesis and schizokinesis established by Gantt in animal experiments. Prognostic models based on experimentally established impairment of performances were shown to predict long-term risks of schizophrenic defects just as well as models based on constellations of clinical symptoms. I would predict that psychophysiology and experimental psychology will become increasingly more important for establishing diagnosis and prognosis in the functional psychoses. The data of this article point toward a basis for a prophylactic psychiatry.     

Learning and teaching (briefly)

This paper was given as the Annual Ellen Noonan Counselling Lecture on July 2012 and retains some of the spoken style of the lecture. It uses examples of Ellen Noonan’s work to examine aspects of the process of teaching and learning psychodynamic practice. The difficulties of how to embed theoretical knowledge with its clinical application are discussed and the question of what are the key skills of the self-reflective practitioner is raised with reference to whether, and how, they can be taught or learnt. It is suggested that part of this process consists in helping students, and their teachers, to be more comfortable with not knowing, a concept that is both counter intuitive and counter cultural. From this aspects of contemporary therapeutic practice, with specific reference to psychodynamic short-term therapy, are addressed. The paper looks at the ambivalence felt by many psychodynamic clinicians towards working within a short-term paradigm in current workplace settings and how this might be addressed. The paper discusses the intrinsic qualities of a psychodynamic short-term approach and its relation to contemporary therapeutic modalities. It is suggested that the increasing managerial culture, leading to the ascendance of protocol driven, manualised and structured therapies, represents an attack on the relational and must be challenged.     

Clinical psychopathological characteristics of acute atypical circular affective psychoses

The clinical reality of acute atypical affective psychoses is recognized by almost all psychiatrists. A total of 229 cases of atypical circular psychosis have been studied. In many of these cases the "psychodynamic mobility" of the personality, i.e., the "fixed attitude" according to Usnadse, was studied in addition to a clinical analysis. The method used for this is described, and a number of criteria for evaluation are reported. Also, the thematic apperception test and Rorschach test as well as electroencephalographic examinations have been carried out on many of the patients included in this study. The results of clinical-psychopathological and experimental-psychological examinations enable better diagnoses of acute atypical affective psychoses to be established.     

Psychodynamic assessment of changes in children with autism under psychoanalytic treatment

In this article the authors report insights into autism developed through their extensive experience of psychoanalytic therapy with children with autism. The fi rst stages of body psychic development are seriously disrupted by this pathology, resulting in primitive anxieties of falling and of being liquefi ed. These anxieties are connected to the fragile development of body ego and of its related spatiotemporal organisation. The changes in children observed by the authors during the therapeutic process lead them to offer a psychodynamic assessment tool, which revolves principally around the development of body ego. After the initial state of 'severe autism', the authors describe three stages: the stage of 'recovery of the skin' (Bick); the established 'symbiotic phase', subdivided into 'vertical then horizontal splitting of the body ego'; and fi nally the stage of 'individuation'. First, the authors describe the principal psychoanalytic approaches to autism and refl ect on the links possible with nonpsychoanalytic work.