Converted patients and clinic patients as control cases: a comparison with implications for psychoanalytic training

All twenty-eight respondents to a recent poll of the thirty institutes affiliated with the American Psychoanalytic Association reported that they now accept cases converted from psychotherapy to psychoanalysis as control cases. This study was designed to compare converted cases to clinic cases systematically with respect to patient characteristics, treatment, and the educational experience of the treating candidate. The study followed twenty-four candidates entering analytic training between 1992 and 1995, who treated thirty-four clinic cases and forty-three converted cases between February 1993 and July 2000. Clinic and converted patients were comparable with regard to demographics, prior treatment histories, structural diagnoses, and Axis I diagnoses. In addition, the two groups of cases were indistinguishable with respect to the rate at which candidates received credit toward graduation requirements. Candidates treating converted cases earned approximately dollars 7,600 per patient per year, compared to candidates treating clinic cases, who earned nothing. Eighty-four percent of converted patients diagnosed with a mood disorder by the treating candidate were on medication, in contrast to only 20% of clinic patients with the same diagnosis. Similar differences were seen in the case of anxiety disorders. Given the prevalence of affective and anxiety disorders in control cases and the availability of a variety of medications and psychotherapies with documented efficacy in treating these disorders, candidates should be trained to discuss treatment options with patients who present with Axis I disorders.     

Countertransference and changes in the conception of the psychoanalytic relationship

Abstract

The concept of countertransference has a long history in psychoanalysis. This paper sketches the phenomenon referred to by countertransference and the development of the concept, from being signs of disturbance in the analyst to an important road to knowledge about the patient's inner life. The complexity of the questions discussed today – how to understand the concepts of neutrality, abstinence, and empathy; the relative subjective mutuality and symmetry of the analytic situation; the analyst's enactments and self-disclosure of feelings – reflects the complexity of the contemporary view of the patient–analyst relationship. In conclusion, the author presents a model illustrating the disturbing and informative aspects of countertransference together with the conceptual relationship between countertransference on the one hand and empathy and projective identification on the other. Finally, by differentiating between intuitive and irrational levels of functioning, an integrated model for countertransference is presented, synthesising the essence of the concept as it is used today.     

The coming changes in psychoanalytic education: Part I

The author presents a critical overview of the literature on psychoanalytic education, focusing on criticism regarding structural aspects of our educational institutions. He then presents arguments for the need of radical changes in the organizational structure of institutes, and focuses on the problems of the training analysis system. He proposes concrete solutions for these problems, in the form of changes both in the assignment of responsibilities for the personal analysis of candidates and in the selection and function of supervisors.     

The coming changes in psychoanalytic education: Part II

This paper is the second part of a general analysis of problems in contemporary psychoanalytic education. Having proposed changes in the training analysis and supervisory systems in Part I, here the author focuses on concrete proposals regarding changes in the curriculum, seminars and classroom teaching; the governance of psychoanalytic institutes, relationship of institutes with their respective psychoanalytic society and the role of the university in the development of science and research; the admission, progression, and graduating processes; certifi cation and accreditation.     

A reassessment of psychoanalytic education: Controversies and changes2

To understand the many controversies surrounding psychoanalytic education, it is necessary first to understand the unique role played by education in our field where control of educational structures remains the most important measure of professional success for the majority of psychoanalysts. To keep debate about educational policy focused on the task of strengthening the intellectual basis of psychoanalysis, it is also necessary to understand that forces affecting education arise from at least three different domains which can too easily become confused with one another: 1) the domain of knowledge‐ intellectual, scientific and clinical; 2) the domain of the organized professional community; and 3) the domain of local institutional politics. The authors explore controversy arising within and among each of these domains. They also explore the major alternatives proposed to the Eitingon model of psychoanalytic education, arguing that excessive authoritarianism in education arises not from the existence of hierarchical structures per se (as suggested by the ‘French model’), but from two other factors: the condensation of all important professional functions into the single ‘monolithic’ position of the training analyst, and the lack of agreed upon methodology for determining the validity of theoretical propositions. The solution lies not in obliterating all gaps in expertise and status by doing away with hierarchical structures altogether, but rather in strengthening the intellectual, scholarly and research context within which psychoanalytic education takes place. We must attempt to relocate our experience of a gap where it belongs: not between those who are training analysts and those who are not, but between what we feel we already know about mental life and what we do not yet know.     

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.     

Being a person in psychoanalytic culture

The author argues that schools of care are really cultures whose practices and teachings are only minimally based in science. Although the early link of mental-health care to medicine was historically fortuitous, bestowing a debatable authority on the field, these schools' consuming preoccupation with scientific legitimacy has severely limited mental-health care professionals' own ability to understand and think wisely about these schools of care. Students of these schools become enculturated into the ideology of a particular school, its notions of what is normal and what is ill, of how life works, and of what patients need to do to become well. The listening tradition of psychoanalysts is admirable, but its discounting of external factors, like an individual's upbringing, race, or even friendships, constitutes a major flaw.Dr. Fancher is author of the forthcoming bookCultures of Healing: Correcting the Image of American Mental Health Care (W.H. Freeman and Co., 1995), from which this article is excerpted with permission.     

Miscarriages of psychoanalytic treatment with suicidal patients2

The author describes a particularly perilous frontier on the psychoanalytic landscape‐ namely, the treatment of suicidal patients with serious personality disorders. Using a clinical example of egregious boundary violations by an analyst, he describes specific countertransference pitfalls that lead to mishandling the patients' expressions of suicidal despair. These include disidentification with the aggressor, failure of mentalization, collapse of the analytic play space, reactions to loss in the analyst's personal life, omnipotence, envy of the patient and masochistic surrender. The author emphasizes the unique vulnerabilities that accompany analytic treatment of such patients.