Editorial

Addressing the issues of intersubjectivity and hermenutics and their relevance for psychoanalysis, the author presents a model for interpreting inspired by the existential hermeneutics of Martin Heidegger. This analysis is then applied to the clinical reality of the psychoanalytical situation. The author discusses the matrix of transference, the analytical dialogue as a form of reflection, the functions of hope and faith, and lastly, truth as faithfulness in the hermeneutic context.     

The Future of Psychology in Medicaid's Health Delivery System for People with Disabilities

State Medicaid programs are rapidly converting fee-for-service health delivery systems to managed care for people with disabilities. In theory, managed care models of health delivery will substantially improve the quality of care for people with disabilities, but in reality, few successful models exist. This period of transition holds both opportunities and challenges for psychologists in medical settings. Because Medicaid reforms for people with disabilities may herald similar reforms for both the public and the private sectors, psychology's response will determine its role in the future of health care delivery for this population. Changes in training and increased attention to outcomes research, innovations in practice, and advocacy will be the keys to success.     

The Doctor-Patient Relationship in the Post-Managed Care Era

The growth of managed care was accompanied by concern about the impact that changes in health care organization would have on the doctor-patient relationship (DPR). We now are in a “post-managed care era,” where some of these changes in health care delivery have come to pass while others have not. A re-examination of the DPR in this setting suggests some surprising results. Rather than posing a new and unprecedented threat, managed care was simply the most recent of numerous strains on the DPR that have occurred throughout the century. These strains are a constant, inevitable consequence of the varying needs and concerns of patient and physicians as they seek to balance their desires for a certain type of DPR with their simultaneous desire for other aspects of care such as lower costs, greater technological sophistication, and improved outcomes.     

“You touched my heart”: Modes of memory and psychoanalytic technique

Abstract

With the concept of procedural unconscious processes, contemporary psychoanalysis goes beyond Freud, who did not know of implicit memory and the resulting procedural relational dynamics. Today, lack of mentalization and symbolization is regarded as another mechanism besides repression constituting the psychodynamic unconscious. From that theoretical background, the manifestation of early pre-reflexive archaic experience can be conceptualized as procedural transference and handled in a way that takes care of the specific functioning inherent to the underlying archaic states of mind. Using material from the analysis of a narcissistic patient, the merging of episodic and procedural modes of transference and how this affected the psychoanalytic technique are demonstrated.     

Transference: current concepts and controversies

In this paper I have presented a brief outline of some of the more important issues regarding transference. To summarize I shall restate ten transference issues heretofore discussed: What should be included in the definition of transference? Should it be defined narrowly or broadly? In what ways can transference be usefully viewed in relation to reality? What merit is there in distinguishing the working alliance from transference? Should self and object transference be differentiated? Should transference neuroses be discriminated from transference reactions on the one hand and from transference psychoses on the other? In addition to sexual and aggressive transferences, should sexualized and aggressivitized transferences, respectively, be distinguished? How may transference be conceived of as a vehicle of cure and yet also as a resistance to cure? What is to be said for the relative merit of the "here and now" versus the "there and then?" What is the role of transference in relation to insight on the one hand and to the therapeutic object on the other? What are some of the basic issues in countertransference?     

Self-Disclosure and Vulnerability

Abstract

Based on the theoretical assumption and clinical observation that projective identification is a natural, constant element in human psychology, clinical material is used to illustrate how projective identification centered transference states create situations where acting out of the patient's phantasies and conflicts by both patient and therapist is both common and unavoidable. Because they are more obvious, some forms of projective identification encountered in clinical practice are easier for the analyst to notice and interpret. Other forms are more subtle and therefore difficult to figure out. Finally, some forms, whether subtle or obvious, seem to create a stronger pull on the analyst to blindly act out.

In some psychoanalytic treatments, one form of projective identification might embody the core transference. In other cases, the patient might shift or evolve from one level of this mechanism to another. Some patients attempt to permanently discharge their projective anxiety, phantasy, or conflict into the analyst. There is a patent resistance to re-own, examine, or recognize this projection. Some of these patients are narcissistic in functioning, others are borderline, and many attempt to find refuge behind a psychic barricade or retreat (Steiner 1993). In other forms of projective identification, the patient enlists the analyst to master their internal struggles for them. This occurs through the combination of interpersonal and intra-psychic object relational dynamics. This “do my dirty work for me” approach within the transference can evoke various degrees of counter-transference enactments and transference/counter-transference acting out.

Another form of projective identification, common in the clinical setting, is when a patient wants to expand the way of relating internally, but is convinced the analyst needs to validate or coach the patient along. This is why such a patient may stimulate transference/counter-transference tests and conduct practice runs of new object relational phantasies within the therapeutic relationship. Over and over, the patient may gently engage the analyst in a test, to see if it is ok to change their core view of reality. Depending on how the analyst reacts or interprets, the patient may feel encouraged to or discouraged from continuing the new method of relating to self and object. The patient's view of the analyst's reactions is, of course, distorted by transference phantasies, so the analyst must be careful to investigate the patient's reasoning and feelings about the so-called encouragement or discouragement. This does not negate the possible counter-transference by the analyst in which he or she may indeed be seduced into becoming a discouraging or encouraging parental figure who actually voices suggestions and judgment.

All these forms of projective identification surface with patients across the diagnostic spectrum, from higher functioning depressive persons to those who are more disturbed paranoid-schizoid cases. Whether immediately obvious or more submerged in the therapeutic relationship, projective identification almost always leads to some degree of acting out on the part of the analyst. Therefore, it is critical to monitor or use the analyst's counter-transference as a map towards understanding the patient's phantasies and conflicts that push them to engage in a particular form of projective identification.     

Treatment of Male Homosexuals in Groups

Abstract

The healing power of psychodynamically oriented therapy and training groups rests, to a large degree, upon the quality of the here and now interactions. For the work to be effective, the basic principles of analytic group work need to be followed, including the observance of no extra–group contact. Simply said, nothing leaves the room. This principle has both ethical and clinical implications. It is my premise that while some forms of outside contact between members are relatively benign, other types are not. Outside contact that is built into the fabric and context of the group may pose a risk, as may be the case where dual relationships exist between members. The impact of dual relationships between group members in the particular instance of analytic training institutes is the focus of this article. What happens to the transference in this context when members reveal too much of their personal lives to each other through dual relationships is explored. It is suggested that extra–group contact can disrupt the balance between reality and transference distortion in group interactions in at least three ways: (a) “The Emperor’s New Clothes” effect, (b) looping, and (c) gaslighting. Vignettes are presented to illustrate these phenomena and suggestions for reform are offered.     

Comment

ABSTRACT

Comments on the role of greed at all levels of the managed care system, from individual patients to corporations. It is suggested that couples therapists not seek inclusion as “health care providers.”     

The Nature of the Transference Between Anna Freud and Melanie Kleins: Learning from the Controversies

As we work through our theories, we rejoice in discovering the logic of concepts and their articulation in clinical experience. Such joy hides other movements, in which the only stakes are demands for love, sexual curiosity and the satisfaction of hate, transferred from infancy to others worlds, idealised or despised. When we participate in our psychoanalytical institutions, we feel pride or even vanity to be participating in the great historical movement of psychoanalysis. This conceals the working of transference in our institutional life; transference which is crudely sexual at its origins, and implies maternal, paternal or fraternal objects. This is its constraining power. We should be fully aware of this, as Strachey or Balint have already shown, in order to attenuate the violence of transference and stimulate our creativity. Anna Freud and Melanie Klein's controversies had a reality of their own. This reality was quickly forgotten and trapped in various conflicts, as those existing between Jones and Freud or between Glover and the rest of the British Psychoanalytical Society of his times. These re-elaborations gave rise to ideological elements, which have ever since pervaded the history of psychoanalytical theory, influencing psychoanalytical methods and clinics. It is important for us today to elucidate these ideologies in order to improve our achievements.     

Conceptualization of hostile psychopathy and sadism: Drive theory and object relations perspectives

Abstract

Turkel A.R. The Gender of the Analyst. Int Forum Psychoanal 1992;l:ll-19. Stockholm. ISSN 0803-706X

The importance of understanding the gender-related aspects of our clinical work should not be underestimated. The problems associated with the choice of the analyst by gender are explored with particular focus on three therapeutic dyads: women treating women, women treating men, and men treating women. While the analyst's gender may contribute to resistance and to negative transference, it may also facilitate treatment. Research studies are examined and clinical material is utilized to illustrate the major points.     

How Managed Care Can Help Couples Cope

ABSTRACT

This article traces how managed care became a quick fix to curb out-of-control healthcare costs rather than a real effective approach to managing care. To date, the impact has been not only a negative experience, but impediment to treating couples facing relationship and related problems. The author is optimistic about how managed care will evolve to recognize the importance of couples and family treatment as we enter the future with integrated systems of healthcare. ? The future will also require significant shifts in the thinking and practice patterns of providers and an emphasis on quality and outcomes.     

Depth of Transference in Groups

An ongoing controversy in the field of group psychotherapy is whether transference regression is greater in groups than in individual treatment. There appears to be a general consensus that group behavior may be understood as operating on at least three levels—the conscious–rational, the oedipally determined transference, and the preoedipal maternal transference level. The more rational levels are associated with transference dilution, whereas the more primitive levels accompany transference intensification. Dilution occurs as a result of reality demands and inputs of the group situation and because of multiple targets of displacement. Transference intensification is a product of mutual stimulation, contagion effect, frustrating inputs, and support of the group theme. Certain patients benefit most from the dilution features of a group, and others profit most from intensification. The therapist's technique and the patient's pathology are the main determinants of which aspect gets emphasized and utilized.     

Existential Marital Psychotherapy and the Experience of Managed Care

ABSTRACT

In this article the experience of managed care is over-viewed from the perspective of existential marital therapy. It is concluded that managed care disrupts the experiential nature of participation between couple and therapist, dilutes the authentic nature of the treatment relationship, decreases the importance of subjectivity, disturbs the discovery of meaning and purpose in marital life and deters existential communication.     

The identity of the sport psychology profession: A multinational perspective

ObjectiveTo ensure public safety, duty of care, and professional advancement, there is a need for scholars to explore factors that impact the professional experiences of sport psychology professionals (SPPs). One such factor is professional identity, which has been shown to positively contribute to an enhanced sense of legitimacy of the profession in the eye of the public and sport stakeholders (i.e., athletes, coaches, sport scientists, administrators) and to positively impact the experience and effectiveness of practitioners. Yet, little research has directly examined the construct of professional identity within sport psychology, with this oversight posing a risk to the future of the profession.DesignThis interview-based study was situated within critical realism. We conducted a qualitative study using semi-structured interviews to explore the understanding and perceptions and experiences of the professional identity among SPPs.MethodsFollowing theoretical criterion-based sampling, we interviewed 33 expert (n = 13), experienced (n = 12), and early career (n = 8) SPPs regarding their views on PI. The nationalities of these SPPs (male n = 16; female n = 17) represented sixteen different countries on four different continents.ResultsData were analyzed using reflexive thematic analysis and showed a relatively shared meaning of professional identity which unfolded across the career span. Moreover, the professionals in this study seemed to identify their pride for and their knowledge of the profession as key factors in the development of their PI. Furthermore, they identified how their professional role, expertise, and interactions with other professionals within the field played an important role in sustaining a professional identity.ConclusionWe interpreted the interview data as supporting the importance of professional identity for SPPs and consider the contribution of this within a developmental framework for effective practice.     

Construction et validation d’une échelle de mesure des représentations sociales du travail informel

IntroductionReliable tools capable of assessing the various dimensions of the representations of informal work are inexistent. This very situation contributes in eliminating the possibilities of quantitative studies on informal work in psychology.ObjectiveThe objective of this study is to put forward a quantifying instrument of the representations of informal work, presenting adequate psychometric qualities.MethodThree case studies have been realized in Cameroon: the first one is qualitative, and enables the identification of considerable elements of the representations of informal work through proper analyses; the last two studies are quantitative. Data are collected with a questionnaire and analysed using exploratory and confirmatory factor analyses through SPSS17.0 and Amos.21 software.ResultsThree dimensions of representations of informal work arises from analyses: nature and security, normative aspects, financial aspects related to informal work. It is also noted that intentions to engage into the restructuring programmes of informal work are significantly oriented by the representations of informal work.ConclusionThus, the convenience of the scale once validated, its perspectives and its limits remain arguable.     

Considerations on medical training for gender-affirming care: Motivations and perspectives

Abstract

Background: Many transgender individuals lack access to needed medical care, partially due to a lack of providers with experience in gender-affirming healthcare.

Aims: The purpose of this study was to identify professional motivators for medical providers seeking out training in gender-affirming care and to define which training experiences were most beneficial to their career development. By identifying experienced providers’ recommendations on which training modalities are most relevant to their practice, we aim to suggest future directions for medical education initiatives to effectively expand the transgender care workforce.

Methods: A voluntary cross-sectional electronic survey was distributed through professional listservs and publicly-available referral lists to interdisciplinary providers who self-identified as having experience in providing care to transgender individuals.

Results: One hundred and fifty-three (n?=?153) physicians, physician assistants, or advance-practice nurses responded to the survey. The majority (96.7%) were located in the United States, representing 37 states. The two most common motivators for seeking out training in gender-affirming care were filling a need in the community (73.0%) and/or having met a transgender-identified person in a clinical setting who requested care (63.8%). While many providers gained skills independently (57.3%), the two most commonly-available training opportunities were professional conferences (57.3%) and mentorship (41.3%). Respondents were most likely to recommend that others in their field be trained via structured clinical experience (e.g., a rotation or longitudinal exposure during training), rather than additional didactic training.

Discussion: This study identifies key high-yield training methodologies which could improve access to quality gender-affirming healthcare. Through integration of structured clinical experiences during training, direct clinical mentorship, and professional development at conferences on gender-affirming care, the workforce of welcoming and prepared healthcare providers for transgender patients will increase. This will lead to a tremendous improvement on access to gender-affirming care in our communities.     

Countertransference as an Ally in Sexual Therapy

SUMMARY

This paper illustrates a constructive use of a persistent countertransference response of a therapist towards a client in sexual therapy. The recognition that the transference resistance from the client had multiple motivations assisted the therapist's constructive use of the countertransference to facilitate the treatment process of the couple.     

Alchemy and the erotic transference: A Jungian approach

Abstract

In The Psychology of the Transference Jung showed a series of pictures which he discovered in an ancient alchemical text, the Rosarium philosophorum. He connected these to the effects of the transference in psychotherapy. This may seem an unnecessarily obscure way of looking at the transference, yet it makes remarkable sense. Although alchemy is often considered the sole province of Jungian analysis, it can also be seen as illuminating a psychodynamic approach to counselling. Written from a post-feminist viewpoint, a critical approach is taken to certain key Jungian terms. The paper is illustrated with two clinical examples.     

Work-related counselling-a psychodynamic approach

Abstract

The paper sets out to stimulate interest in counsellors and therapists about the unconscious relationships which people form with their work, through describing and analysing what goes on in work-related counselling with a psychodynamic approach. The author draws on twenty-five years of experience to reflect on the changing nature of what was once termed ‘vocational guidance', and offers some short case studies, as examples of ways in which a person's world of work can become intertwined with their internal world in a confusing and disabling way. The core concepts and techniques which have evolved are identified and discussed; attention is directed particularly to the importance of the client's expectations, die effect of time limitation, the place of work in the whole life, and dealing with transference.